Claims Processing Changes - 5010 and 1500July 13, 2011
How does 5010 affect your office? How concerned should you be? Will 5010 change the 1500 or UB04 claim forms?
The 5010 format implementation is a current "hot topic" for providers and billers. This helpful Q and A segment should help clarify what is going on.
Q: What is Version 5010?
A: Version 5010 is the upcoming replacement of X12 standards (837p & 837i) for HIPAA standard electronic claims submission. Technically it is only for electronic claims. Here's the official statement:
"The Secretary adopted version 5010 to replace the current version of the X12 standard that covered entities (health plans, health care clearinghouses, and certain health care providers) must use when conducting electronic transactions including: claims (professional, institutional and dental), claims status requests and responses, payment to providers, eligibility requests and responses, referral requests and responses, enrollment and disenrollment in a health plan, Coordination of Benefits and premium payments.
The Secretary also adopted version D.0 to replace the current version of the NCPDP standard covered entities must use for pharmacy and supplier transactions including: claims, eligibility requests and responses, referral certification and authorization and Coordination of Benefits.
The current versions of the standards (the Accredited Standards Committee X12 Version 4010/4010A1 for health care transactions and the NCPDP Version 5.1 for pharmacy and supplier transactions) are widely recognized as lacking certain functionality that the health care industry needs." - Centers for Medicare and Medicaid Services (CMS)
Q: When is it effective?
A: This depends on who you are. NOW is the time for external testing of electronic claims. Most providers need only to be concerned with the final compliance date of January 1, 2012. CLICK HERE for more information.
Q: I heard that 5010 was being delayed. Is it?
A: While in the testing phase, it is not uncommon to run into problems. One current problem with the Medicare testing of the 5010 format has to do with the paperwork segment. Until they fix that problem, the supporting paperwork (PWK) portion is on hold. The rest of claims testing goes on as planned.
There is no delay. As of January 1, 2012, the version 4010 will not be accepted. This is a HIPAA regulation for all payers, not just government programs.
Q: What does this mean to me?
A: If you are filing claims electronically and use a clearinghouse, you may have already received notice from your clearinghouse that testing is beginning or will begin very soon.
Q: Why change now?
A: Much of it is due to the fact that ICD-10-CM / ICD-10-PCS will be replacing ICD-9-CM in 2013. Everyone needs to be ready to make that switch without a problem. That is why there is extensive testing going on now.
Q: I don't file electronically. What is happening to the paper claims?
A: As of today, there are no official changes to either the 1500 or UB04 paper claim forms. Some changes have been suggested because of the 5010 format changes, but nothing is official yet.
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