We began submitting claims in the new HIPAA 5010 compliant format to Emdeon and Anthem BCBS of Ohio on November 9th, 2011, and to CGS Medicare on February 20th, 2012.
All practices need to be aware that this may impact your cash flow from payers. Areas to review for potential problems:
- Insurance Claim Errors within StreamlinePM+
- Insurance Electronic Rejections
- Insurance Denials
If you identify or suspect any claims submission issues related to 5010 submission, or if you have questions on which payers are impacted for your practice, please contact the PRC Medical / StreamlineMD HELPDESK at 1-866-460-0388.
To view a complete list of payers with Emdeon, see https://access.emdeon.com/PayerLists/.
PRC Medical / StreamlineMD will continue to keep you informed as we go live with additional vendors / payers.
Below are answers to key questions regarding our HIPAA 5010 claim submission compliance.
What is the 5010 version of the HIPAA X12 Electronic Data Interchange Standards? The Department of Health and Human Services (HHS) has issued updated standards for the electronic transmission of healthcare transactions, including: eligibility verification, claims submission, remittances, claim status, and referrals. Covered entities must upgrade from the current X12 4010 A1 version to the 5010 version.
Who is required to update to 5010? When does it need to be implemented? Covered entities, including healthcare providers, health plans and clearinghouses must update to 5010 by January 1, 2012.
What transactions are specified in the 5010 standards?
- 270/271 Health Care Eligibility Benefit Inquiries and Response
- 276/277 Health Care Status Request and Response
- 278 Health Care Services – Request for Review and Response
- 835 Health Care Claim Payment/Advice
- 837 Health Care Claim (Professional, Institutional, and Dental)
What are the benefits of upgrading to the 5010 standards?
- Provides infrastructure for the ICD-10 code sets
- Resolves ambiguities in situational rules
- Supports standardization of companion guides across the industry
- Eliminates unnecessary or redundant data elements
- Improves consistency across transactions
- Supports pay for performance
- Streamlines reimbursement transactions
What are the suggested timelines by HHS to help organizations meet the compliance dates? HHS recommended the following timelines to help the industry migrate to the new 5010 version. Target Date Description:
- December 31, 2010 - Achieve Level 1 compliance (covered entities can send and receive compliant transactions).
- January 1, 2011 - Begin Level 2 compliance testing with trading partners and move into production. Support dual 4010 A1 and 5010 processing.
- January 1, 2012 - Full compliance of 5010 standards for all healthcare covered entities.
How did PRC Medical / StreamlineMD preparing for migration to 5010? We completed a gap analysis between the 4010 A1 and 5010 standards to determine the impact on our existing StreamlinePM+ software. We made all changes necessary within our StreamlinePM+ practice management system and claim submission rules engines for 5010 compliance. We continue to work with new and existing trading partners to fine tune claims submission and adjudication in 5010 formats.
Does PRC / StreamlineMD allow processing of both 4010 A1 and 5010 transactions? Yes. Our claims are submitted to Emdeon in 5010 format. Emdeon converts to 4010 A1 for payers that are not yet 5010 compliant.
For additional information regarding PRC Medical / StreamlineMD ANSI 5010 readiness, please contact Frank Hill at fhill@prcmedical.com or 330.564.2603.