4010 to 5010 - e3 Informatics

4010 to 5010

Don’t Get Left In The Dust

Vince Joyce, CPHIMSSenior Consultant, E3 Informatics LLC

Member ANSI ASC X12

Disclaimer

• Presentation is based on: – ANSI ASC X12 Implementation Guides

– Information from the Health Information and Management Systems Society (HIMSS)

– Information from CMS

– Information from WEDI

• The presentation is not based on:– NC DMA directives

– HP/EDS directives

5/10/2011 2

Topics

• What is 5010?

• Why the change?

• Who is effected?

• What is the timeframe?

• Which EDI transaction sets are being updated?

• What are the major changes?

5/10/2011 3

Topics

• How do I update my software?

• Do I have to test with my Trading Partners?

• What are the implications for 1915(b)(c) waiver sites?

• Where can I get more details?

5/10/2011 4

What Is 5010?

• 5010 is the new set of electronic data interchange (EDI) formats developed by ANSI ASC X12N.

• ANSI – American National Standards Institute

• ASC – Accredited Standards Committee

• X12N – ASC Subcommittee on Insurance EDI

• 5010 will replace 4010, which has been in place since 2000.

• HIPAA compliant formats for electronic claims

5/10/2011 5

How Can I Tell If My Files Are In 5010 Format?

• 4010

– GS*HC*SENDERID*RECEIVERID*19940331*0802*1*X*004010X098~

– REF*87*004010X098D~

• 5010

– GS*HC*SENDERID*RECEIVERID*19940331*0802*1*X*005010~

5/10/2011 6

Why The Change?

• 4010 is outdated and sometimes vague– 10 years have passed since the last guidelines

were published

– May loops, segments and fields really do not fit the way we do business

– Situational field use is confusing

– Names and addresses are often truncated

– Subscriber and patient loops are used inconsistently

– Payer companion guides are inconsistent

5/10/2011 7

Why The Change?

• 4010 is outdated and sometimes vague– NPI implementation has been confusing (sub-

parts…Billing Provider versus Service Facility)

– The current transaction sets can not accommodate ICD-10

– The current transaction sets are not in line with the rules established in the Affordable Care Act (ACA)

– We still lack standardization

– The healthcare industry has evolved

5/10/2011 8

Why The Change?

• 5010 will provide needed changes– 5010 includes more than 500 structural and

content changes

– 5010 provides more consistency within transaction sets and across transaction sets

– 5010 provides clearer directions on the use of situational fields

– 5010 provides for more consistent NPI use

– 5010 provides improvements in Coordination of Benefits (COB) reporting

5/10/2011 9

Why The Change?

• 5010 will provide needed changes

– 5010 provides improvements in pharmacy reporting

– 5010 provides better flow of cross-over claims

– 5010 accommodates ICD-10

– 5010 better accommodates Affordable Care Act rules

– 5010 eliminates obsolete and unused loops, segments and fields

5/10/2011 10

ICD-10 Implementation

• Implementation date is October 1, 2013.• We are years behind the rest of the world in using

ICD-10.• ICD-10 codes have a different format.

– Begin with letters– Have more digits (more decimal places)

• ICD-10 definitions are much more specific.– Number of codes will triple

• There is not an easy cross walk between ICD-9 and ICD-10.

5/10/2011 11

Who Is Effected?

• Any organization or individual who transmits healthcare related EDI transaction sets

– Healthcare Providers

– Payers

• Insurance Companies

• Insurance Third Party Administrators (TPA)

• Medicare

• Medicaid

• LMEs

5/10/2011 12

Who Is Effected?

• Any organization or individual who transmits healthcare related EDI transaction sets

– Health Plans

– Managed Care Organizations

• 1915(b)(c) waiver sites

– Utilization Management or Review Organizations

– Clearinghouses

– Billing services

5/10/2011 13

What is the Timeframe?

• In August 2008, the US Department of Health and Human Services published a proposed implementation date of January 1, 2010.

– More than 1000 stakeholders asked for the implementation to be postponed.

• In January 2009, US DHHS published the final rule with a January 1, 2012 implementation date.

• In October 2010, several Errata documents were published relating to 5010.

5/10/2011 14


• Proposed Provider/Payer Testing Schedule Published in Federal Register– January 2009 – Publish Final Rule

– January 2009 – Begin Gap Analysis

– January 2010 – Begin Internal Testing

– December 2010 – Internal Testing Complete

– January 2011 – Begin Testing with Trading Partners

– January 2012 – Full Compliance

5/10/2011 15


• The Federal Government has not budged on the January 1, 2012 date.– The US is behind in adopting ICD-10.

– Medicare established 5010 testing protocols in 2010.

– Medicare has been accepting 5010 test transaction sets since January 2011.

– CMS has already provided teleconference and webinar training.

– Medicare is already taking production 5010 transaction sets.

5/10/2011 16


YOU NEED TO BE READY BY

JANUARY 1, 2012

5/10/2011 17

Which Transaction Sets Are Effected?

• All healthcare claims transactions sets– 837P (Professional Outpatient Claims)

– 837I (Institutional, or Inpatient, Claims)

– 837D (Dental)

• Healthcare Claim Payment/Advice– 835

• Functional Acknowledgment– 997 is being replaced with 999

– Proprietary error reporting is being replaced with 277CA

5/10/2011 18


• Healthcare Eligibility Files– 270 Eligibility Inquiry

– 271 Eligibility Response

• Claim Status Files– 276 Claim Status Inquiry

– 277 Claim Status Response

• Request for Referral/Authorization and Response– 278

5/10/2011 19


• Payroll Deducted or Other Premium Payment

– 820

– Used to transmit PMPM (dollars!) for CapitatedHealth Plans

• Benefit Enrollment and Maintenance

– 834

– Used to transmit eligible members for MCOs

– Used to transmit IPRS target pops

5/10/2011 20

What Are the Major Changes?

• 837P – Professional Outpatient Services

– Billing Provider Changes (Loop 2010AA)

• Billing Provider must be a healthcare provider.

• Billing Provider can not be a billing service.

• Billing Provider address must be a physical address.

• Billing Provider address can not be a PO box or a lock box.

• Billing Provider zip code must be 9 digits.

• Billing Provider must use the same NPI number with all Trading Partners.

5/10/2011 21


• 837P – Professional Outpatient Services– Pay To Provider Changes (Loop 2010AB)

• Under 4010, 2010AB is used only if the Pay To Provider is different from the Billing Provider.

• Under 5010, 2010AB is used if Pay To Provider is different from the Billing Provider OR if the Billing Provider wants the check sent to a PO box or lock box. No NPI is used in 2010AB.

• If a PO box or lock box is used, the Billing Provider name and NPI would appear in both loops, but the box number could only appear 2010AB.

5/10/2011 22


• 837P – Professional Outpatient Services– Service Facility Location Changes (Loop 2310D)

• Under 4010 and 5010, this loop is used to identify where the service was performed.

• 2310D should only be used if the Service Facility Location address is different from the Billing Provider Address.

• Under 4010, the Service Facility NPI could be a subpart of the Billing Provider NPI.

• Under 5010, the Service Facility NPI CAN NOT be a subpart of the Billing Provider NPI.

5/10/2011 23


5010 NPI Use Example: Subparts

Raleigh Based MH Provider

NPI 2222222222

Charlotte Clinic

NPI 3333333333

Asheville Clinic

NPI 4444444444

Greenville Clinic

NPI 5555555555

5/10/2011 24


5010 NPI Use Example: Subparts

• The Billing Provider (Loop 2010AA) must represent the LOWEST level of NPI enumeration

• Raleigh, Charlotte, Asheville and Greenville would each be its own Billing Provider

• There would be NO Service Facility Location Loop (2310D)

5/10/2011 25

What Are the Major Changes?5010 NPI Use Example: Subparts

NM1*85*2*GREENVILLE CLINIC*****XX*5555555555~N3*123 STREET~N4*GREENVILLE*NC*280001234~REF*EI*561234567~HL*2*1*22*0~SBR*P*18*******MC~NM1*IL*1*DOE*JOHN****MI*987654321~N3*ABC AVENUE~N4*GREENVILLE*NC*28000~DMG*D8*19580101*M~NM1*PR*2*NCXIX*****PI*DNC00~CLM*233445*16.92***12::1*Y*A*Y*Y*B~HI*BK:317~NM1*82*1*WELBY*MARCUS****XX*1234567890~PRV*PE*ZZ*456121000X~

Greenville Clinic provided the service and is therefore the Billing Provider. There is no Service Facility Location reported.

5/10/2011 26


5010 NPI Use Example: No Subpart

Raleigh Based MH Provider

NPI 2222222222

Charlotte Clinic

NPI 2222222222

Asheville Clinic

NPI 2222222222

Greenville Clinic

NPI 2222222222

5/10/2011 27


5010 NPI Use Example: No Subparts

• The Billing Provider (Loop 2010AA) must represent the LOWEST level of NPI enumeration

• The Raleigh home office would be the Billing Provider with Raleigh NPI

• The Greenville clinic would be the Service Facility Location with NO NPI

5/10/2011 28

What Are the Major Changes?5010 NPI Use Example: No Subparts

NM1*85*2*RALEIGH OFFICE*****XX*2222222222~N3*567 STREET~N4*RALEIGH*NC*271121234~REF*EI*561234567~HL*2*1*22*0~SBR*P*18*******MC~NM1*IL*1*DOE*JOHN****MI*987654321~N3*ABC AVENUE~N4*GREENVILLE*NC*28000~DMG*D8*19580101*M~NM1*PR*2*NCXIX*****PI*DNC00~CLM*233445*16.92***12::1*Y*A*Y*Y*B~HI*BK:317~NM1*82*1*WELBY*MARCUS****XX*1234567890~PRV*PE*ZZ*456121000X~NM1*77*2*GREENVILLE CLINIC~N3*123 STREET~N4*GREENVILLE*NC*280001234~

Raleigh Office is the Billing Provider because only the home office has an NPI number. Greenville Clinic is reported as the Service Facility Location with no NPI.

5/10/2011 29


• 837P – Professional Outpatient Services– Diagnoses Changes

• Segment and fields are expanded to accommodate ICD-10 in October 2013.

• The 837P can include up to 12 diagnoses.

• The 837P can have up to 4 diagnosis pointers.

– Taxonomy Code Changes• The payer CAN NOT dictate which taxonomy code you

must use.

– NPI is required except for atypical providers

5/10/2011 30


• 837P – Professional Outpatient Services– Coordination of Benefits (COB) Changes

• AMT segments that can be calculated have been removed.

• The remaining patient responsibility amount is more clear.

• Balancing the original claim amount against COB information and the remaining amount is more clear.

• The improvements in Subscriber/Patient segments will mean better claim flow when there are multiple third party payers.

5/10/2011 31


• 837P – Professional Outpatient Services– Subscriber/Patient Segment Changes

• With 4010, there is sometimes confusion about whether a healthcare consumer is a Subscriber or a Patient

• With Commercial Insurance, there is often a Subscriber (policy holder) and a Patient (spouse or child)

– There is usually a group policy number

– There may or may not be unique identifiers for each member

• With Medicaid and Medicare, the healthcare consumer is always the Subscriber

5/10/2011 32


• 837P – Professional Outpatient Services

– Subscriber/Patient Segment Changes

• With 5010, if a healthcare consumer has his or her own unique identifier with the insurer, then the consumer is considered a Subscriber.

• This should make Third Party Liability determination and COB more consistent

• Your staff must be very careful when recording and verifying third party coverage and policy numbers.

5/10/2011 33


• 837I – Institutional (Inpatient) Services– Many of the changes are the same as the 837P.

• Billing Provider/Pay to Provider

• Service Facility Location

• COB

• Subscriber/Patient

• ICD-10

– There is a clearer distinction between Inpatient and Outpatient Services

– There are additional diagnosis differences.

5/10/2011 34


• 837I – Institutional (Inpatient) Services– Allows for more Diagnoses

• One Principal Diagnosis

• One Admitting Diagnosis

• Up to three “Reason for Visit” Diagnoses

• Up to twelve E code Diagnoses (external causes of injury or condition)

• Up to twenty-four Other Diagnoses

• Added a “Present on Admission” indicator

5/10/2011 35


• 997 – Functional Acknowledgment– The 997 is being replaced with a new file called

the 999.• Similar to 997, but more detailed

– There will be another new file called a 277CA• Will replace proprietary error files, such as the error file

used by Medicare

• Shows rejected claims and claims accepted with errors

– 824 file is not mandated part of the Healthcare 5010 updates

5/10/2011 36


• 835 – Claim Payment and Advice– 5010 provides clearer definitions regarding

payments, adjustment and denials– More consistent use of Claim Remark Codes– Clearer instructions on documenting

recoupments, reversals and corrections– Stronger requirements on balancing claim

amounts, payments, adjustments and denied amounts

– Adds information on Payer’s Medical Policy

5/10/2011 37


• 270/271 – Eligibility Inquiry and Response

– 5010 requires alternative search options for identifying the member.

– 5010 clarifies instructions for identifying status of covered member.

• Subscriber

• Patient

• How to report covered member on secondary and tertiary claims

5/10/2011 38


• 270/271 – Eligibility Inquiry and Response

– 5010 includes information on primary and secondary insurance.

– 5010 includes information on patient responsibility.

• Copay

• Deductible

• Co-insurance

• Out of pocket limits

5/10/2011 39


• 270/271 – Eligibility Inquiry and Response– 5010 adds 38 new Service Category Codes.– Major Service Category Codes are:

• Medical Care• Chiropractic Care• Dental Care• Hospital Care• Emergency Services• Pharmacy • Professional Visit –Office• Vision Care• Mental Health• Urgent Care

5/10/2011 40


• 276/277 – Claim Status Inquiry and Response

– Subscriber and Patient loops are used more consistently

– 5010 eliminates some patient sensitive information not required for status check.

– 5010 provides more detail on the claim status.

– 5010 allows more than one Status loop, so multiple status codes per claim may be reported

5/10/2011 41


• 278 – Request for Referral/Authorization and Response

– 5010 includes segments to report more detail on the patient’s condition.

– 5010 provides for more detail on authorizations.

– 5010 adds Mental Status information.

– 5010 accommodates ICD-10.

– 5010 adds a PWK segment to support attachments

5/10/2011 42


• 278 – Request for Referral/Authorization and Response

– 5010 supports event level service reviews.

– 5010 adds information on Durable Medical Equipment (DME)

– 5010 adds information on Functional Activity Limits.

– 5010 adds information on Activities Permitted.

5/10/2011 43


• 834 – Benefit Enrollment and Maintenance

– 5010 clarifies the use of full file replacement versus covered member updates.

– 5010 accommodates ICD-10 codes.

– 5010 adds additional Maintenance Reason Codes.

– 5010 adds privacy options for covered members.

– 5010 adds new Policy Amount Qualifiers.

5/10/2011 44


• 820 – Payroll Deducted or Other Premium Payment– 5010 changes the use of RMR from situational to

required.

– 5010 adds loop regarding services, promotions, allowances and charges.

– 5010 adds information on Receiver’s remittance delivery method

– 5010 add loop regarding Outer Adjustments• Organizational Summary

• Individual Remittance

5/10/2011 45

WHAT DO I DO NOW?!?!

5/10/2011 46

First Things First

• Do you have nine digit zip codes for all of your locations?

• Do you have a PO box or a lock box listed as your Billing Provider address?

• Do you need to take a look at your NPI set up?

• How are your Billing Providers and Service Locations set up?

• Do you need to get companion guides from your payers?

5/10/2011 47

First Things First

• Which transaction sets do you use?

• Do you need to buy the ANSI ASC X12 implementation guides?

• Have you contacted your software vendor?

• Have you thought about who is going to be in charge of this?

• Have you thought about who is going to work on this?

5/10/2011 48

Update Your Software

• Identify all software and integrated systems affected by 5010.

• Look at your workflow and work processes.

• Identify which of you transaction sets are affected by 5010.

• Identify the specific 5010 changes that affect your business.

• Identify the software changes needed .

5/10/2011 49


• Does the software changes and the 5010 changes require you to change your work flow?

– Do you need a gap analysis?

– Do you need to develop Use Cases?

– Are you going to need staff training?

– Are you going to need additional staff?

5/10/2011 50


• Talk with your software vendor.

• Don’t just ask whether they are ready for 5010, ask specific questions!– Which transaction sets are they updating?

– What is the timeframe for delivery?

– Are they staggering delivery?

– What is their internal testing protocol?

– How will the updates be delivered?

– Is training required?

5/10/2011 51


• Do you have a “home grown” system?

– Perform a 4010 to 5010 gap analysis.

– Add or edit tables and fields to accommodate 5010 loop, segment and field changes

– Update your edi mapping.

– Update your code sets.

– If you are using “plug in” programming code such as InterDev, make sure you have the updated “SEF” files

5/10/2011 52


• How do I test?

– You need to schedule internal testing.

• Your software vendor may have tested, but you need to do your own testing.

• Develop scripted testing, especially for your most critical processes.

– Correct claims generation

– Auto-posting

– COB processing

• Anticipate bugs and allow time for fixes.

5/10/2011 53


• How do I test?– You need to schedule testing with your Trading

Partners.• Providers to Medicaid and Health Choice• Providers to Medicare• Providers to LMEs• Providers to Commercial Insurance• Providers to Clearinghouses• LMEs to Providers• LMEs to the State for IPRS• Possibly, 1915(b)(c) LMEs to the State for Medicaid shadow

reporting

5/10/2011 54


• How do I test?– Run your test files through a testing service or

testing software• Claredi

– Now part of OptumInsight Group

• Faciledi– Automated Claredi functionality, great for LMEs and

1915(b)(c) waiver sites

• Only Connect First Pass– Inexpensive desktop software available from Washington

Publishing Company

5/10/2011 55


• Payers will need to update their companion guides

– Medicaid and Health Choice

– IPRS

– LMEs

– Medicare

– Commercial Payers

5/10/2011 56

What Are the Implications for 1915(b)(c) Waiver Site?

• The State and Mercer will probably be looking for:– 5010 implementation plans and timetables– Policy and procedures that relate to specific

procedures affected by 5010• Member eligibility verification, reconciliation • Enhanced COB

– Progress toward software updates– ICD-10 implementation plans– Testing protocols both internally and with Trading

Partners

5/10/2011 57


• What are the most important transaction sets to address first?

– 837P, 837I, 835, 820 and 834 are critical

– 270/271

– 999 and 277CA

– 276/277

– 278

5/10/2011 58


• Eligibility reconciliation is tremendouslyimportant.– 820 will transmit your PMPM monthly.

– 834 will transmit your member eligibility monthly.

– The Global Eligibility File will transmit member eligibility updates daily.

– The files don’t always match!!!

– Are you getting paid for all of the members you have to cover?

– Are you getting paid for members who lost eligibility?

5/10/2011 59


• Educate your contracted providers about 5010 requirements.

• Because of the increased volume in claims, try to get your contracted providers to use EDI.

• Let the computers do the work.

• Because you are administering Medicaid funds, you need to be particularly careful about HIPAA compliance

5/10/2011 60

Where Can I Get More Details?

• Official Implementation Guides and Errata– Available from ANSI ASC X12 online store

– Expensive!• $2500 for the nine major HIPAA related guides

• $940 for the acknowledgment files (999 and 277CA)

• Guides can be purchased separately

– Discounts are available though certain organizations• CMHC/MIS National Users Group (NUG)

• ANSI ASC X12 Members

5/10/2011 61


• www.himss.org

• www.getready5010.org

• www.x12.org

• www.wpc-edi.com

• www.wedi.org

• www.icd10watch.com

5/10/2011 62

http://www.himss.org/

http://www.getready5010.org/

http://www.x12.org/

http://www.wpc-edi.com/



http://www.wedi.org/

http://www.icd10watch.com/


• www.cms.gov/Versions5010andD0/01_overview.asp#TopOfPage

• www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp

• [email protected]

5/10/2011 63

http://www.cms.gov/Versions5010andD0/01_overview.asp

http://www.cms.gov/Versions5010andD0/01_overview.asp

http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp

http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp

mailto:[email protected]

The End (or Maybe the Beginning!)

• Questions

• Comments

• Frustrations

• Screams and Yells

5/10/2011 64

Date post:	03-Feb-2022
Category:	Documents
Upload:	others
View:	2 times
Download:	0 times

4010 to 5010 - e3 Informatics

Documents