As of January 1, 2012, all healthcare providers were required to transition from version 4010/4010A to version 5010 standards for submitting electronic transactions, and the failure to comply may result in claim denials or a government investigation. CMS has repeatedly postponed enforcement, but it appears the agency will begin to enforce civil monetary penalties against non-compliant medical practices, hospitals and other healthcare entities as of July 1, 2012.
If you are compliant, you may have noticed that not all public and private payors are currently compliant and able to accept transactions in version 5010 standards. This means that you will have to continue submitting transaction forms in both version 4010/4010A and version 5010 standards until all payors complete the transition. It is important that you contact each payor and establish a relationship with their HIPAA compliance department to determine their compliance level and promote a fluid transition to version 5010 standards.
If you are not currently in compliance, it is imperative that you begin to develop a transition plan to incorporate the steps your practice will take to become compliant by the enforcement date. In developing your plan, you should be in contact with your payors to provide you with valuable assistance.
Additionally, you may have noticed that one or more of your payors and your practice systems are interpreting codes differently. With the patchwork switchover to version 5010 by providers and payors, this transition has caused significant delays in claims payment, even resulting in denied claims and a decrease in operating cash flow. It is important that you monitor and acknowledgement transactions to ensure that any problem with the format or data content of the transaction form is promptly addressed. We offer the following recommendations to assist in this transition:
- Consider using a clearinghouse to “up-convert” and “down-convert” until your practice can catch up or until all your payors are in compliance with implementing version 5010 standards. There are additional rules that allow clearinghouses and payors to accept standard data from providers and convert it to non-standard data and vice versa.
- Contact your clearinghouse if you notice that one or more of your payors and your practice are interpreting codes differently. Clearinghouses, which have experience with payors at a greater volume, will probably, have a much better idea of how payors are interpreting codes.
- Contact your practice management vendor if you have one. Your vendor should be able to provide you with the information you need to make the transition or to maintain a system for submitting transaction forms with version 4010/4010A and version 5010 standards until all payors are in compliance. It is also likely that your vendor purchased implementation guides.
- Be aware of common problems already experienced in the transition:
- The provider’s claim submission cannot contain a P.O. Box for the facility address. However, providers may use P.O. Box and lock box addresses in the “Pay-to-Provider” information section for where payment is to be sent. This oversight has caused a majority of the rejections for providers who have otherwise successfully transitioned.
- The 9-digit zip code for the billing provider must be populated on the 5010 forms.
- Do not list “default” numbers for the last four digits. An example of a “default” listing would be 12203-0000 or anything where the last four digits do not match the actual last four digits of the billing address.
- Special characters cannot be used on the new 5010 forms, including (#) (;) (‘) and (-); these must instead be spelled out or avoided.
- Other changes, including the change in certain data fields from situational to required will also result in rejection if oversight during the transition occurs.
This post was contributed by Charles Dunham.