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Be 5010 Compliant to Prevent Claim Rejections

June 22, 2011

The January 1, 2012 deadline to be in compliance with the Version 005010 (5010) HIPAA electronic administrative transactions is fast approaching. All providers, payers and clearinghouses that submit HIPAA transactions must use only the 5010 transactions as of the deadline.

Providers need to complete these steps to be prepared for the deadline:

Understand Data Reporting Changes

Not all of the 5010 changes are IT changes and some will impact your business functions. 

  • Talk to your vendor, billing service and/or clearinghouse about resources they have on the 5010 changes. 
  • Identify the data reporting changes that impact your practice. Here are a few of the changes:
    • You can no longer report a PO Box in the Billing Provider Address field. You must now report PO Box addresses for payment purposes in the Pay-to Address field.
    • You must report a 9-digit ZIP code in the Billing Provider and Service Facility Location address fields.
    • A patient with a unique health plan member ID is reported as the subscriber.
    • You can no longer report units of anesthesia time. You can only report minutes.

Upgrade Practice Management System/Electronic Health Record System

You will need to upgrade your practice management system/electronic health record so it can capture the required 5010 data.  

  • Work with your vendor to have the necessary system upgrades completed. 
  •  Determine the costs for the vendor upgrades.
  • Update other manual processes used in the practice to collect and report transaction data.
  • Complete internal testing of the upgrades to make sure your system can generate the 5010 transactions.  Ask your vendor if it will complete the internal testing for you.

Testing the 5010 Transactions

You need to test your upgraded system to make sure your 5010 transactions are working correctly.

  • Test the 5010 transactions with your payers through the channels you use today to send and receive transactions. Specifically test with the payers and clearinghouses that make up your highest volume and/or highest dollar amount of claims.
  • Talk to your vendor about what testing it will do of your system upgrades. Do not assume that your vendor will take care of your testing needs. 
  • Talk to your billing service, clearinghouses or payers about the processes they will be using for testing.  Follow their procedures and make certain that your testing is completed. 
  • Work with your vendor to fix any issues identified during testing and re-test with your clearinghouses and payers.

Minimize the Impacts of Disruptions in Transactions

Since there will be no delay in the compliance deadline, a major concern is the potential for disruptions in transaction processing after January 1, 2012. Providers should develop a “back-up plan” or safety net to address what they will do if their transactions are not working and they are not receiving payments. 
Go to the Centers for Medicare & Medicaid Services’ website for additional information: www.cms.gov/Versions5010andD0

Keep up-to-date with BlueCross BlueShield of South Carolina's 5010 conversion at www.hipaacriticalcenter.com.




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