ANSI 5010

Deidre Lawson Fryfogle- Product Manager

What is ANSI 5010?

• ANSI 5010 is a new electronic format that is being mandated by the federal government for all electronic claims submissions.

Benefits of ANSI 5010

• Provides infrastructure on ICD-10 and Present on Admission Indicator

• New Standard ANSI Responses– ANSI 277CA (Level 2 response)– ANSI 999 (Acknowledgement)

Transactions Converting to ANSI 5010

• ANSI 837 – Professional, Institutional, and Dental claims

• ANSI 835 – Electronic Remittance Advice• ANSI 270/271 – Eligibility Verification• ANSI 276/277 - Real Time Claim Status

ANSI 5010 Changes

• Billing Provider Loop (2010AA)– Cannot send P.O. Box in N3 Address segment.– 9 digit zip code is required for the billing provider.

ANSI 5010 Changes Cont.

• Facility Loop (2310C)– 9 digit zip code required in Facility Address

• Added REFs to support provider Legacy PIN number (moved from 2010AA)

• Loops and Segments have been removed or changed.– Responsible Party and Purchased Service providers are

deleted– DME information moved to FRM segments

ANSI 5010 Changes Cont.

• Additional Segments added to better report specialized information

• Ambulance pickup and drop off locations added

• COB requirements have been modified

• Allow up to 10 Other Insurance Payers to be reported

ANSI 5010 Conversion• We have provided multiple utilities to help make your provider records

5010 compliant.• The new Fields button allows the vendor to have access to all of our fields,

both 4010 and 5010, as well as access to our data mapping.

Provider Address Update

• A new vendor utility will allow you to update the billing and pay-to addresses for all provider records for a customer. • Search Tools Report Manager Provider

Address Update

Provider 5010 Readiness

• Practice Insight has partnered with USPS to do a one time sweep to validate the provider address and update with the 9 digit zip code.

• The Provider 5010 Readiness report will allow you to identify the providers that are still not 5010 compliant.• Missing a 9 digit zip• P.O. Box in the billing• Search Tools Report Manager Provider 5010 Readiness

Post Conversion Routine

• For those new 5010 claim-level errors that may be difficult for your PM to account for, Practice Insight has created a Post Conversion Routine, which will allow us to automatically substitute customer specific claim data upon claim conversion from 4010 to 5010.– Available upon request

EDIFECS Engine for 5010 Claims

• What is EDIFECS? According to their website: “Edifecs XEngine is an enterprise-strength, high-throughput message processing engine that provides deep (SNIP Levels 1-7) and accurate validation of transactions at the edge-of-the-enterprise.

By catching errors early, XEngine separates good data from bad data thus allowing organizations to comply with legislative and company mandates.”

EDIFECS Engine for 5010 Claims Cont.

• In other words, EDIFECS provides an extra level of validation and testing for our ANSI 5010 claims.

• As an extra measure to make sure that all of our 5010 claims are compliant, all 5010 claims process through the EDIFECS validator before being sent to the payer.

• A new status response with a source of EDIFECS will be returned on all claims found in error. The claim status will be INVALID.

Additional Program Modifications

• All of the 5010 screens for Professional and Institutional claims have changed to accommodate the change in data for these formats.

5010 Industry Timelines

• Mandatory compliance on January 1, 2012 for all covered entities

• Small health plans have until January 1, 2013

• ICD.10 compliance is October 1, 2013

Practice Insight Timelines

• Participating in the National Testing Week with CMS the week of August 22 – 26, 2011.

• Scheduled to begin transitioning payers to 5010 format this September.

• http://www.practiceinsight.net/pi-website/page52.htm• Weekly emails will be sent with notifications of payer

transitions.• All payers to be switched to ANSI 5010 by December 31,

2011.

What You Can Do To Prepare

• Educate yourself on the format change. Purchase the new ANSI guides(WPC-edi.com)

• Start using 9 digit zip codes!!!‣ Facility records in Practice Management

‣ Provider records in PM and PI• Identify your customers with PO Box addresses in the

Billing Provider loop move this to the Pay-To Provider loop

• TEST! If you would like to test your claims, please contact PI and we can give you instructions on how to test.

What to Watch Out For

• With all ANSI transaction formats changing:–Watch claims–Watch responses–Monitor Payments–Stay ALERT!!

Be a Hero!!

Be proactive! Your providers are counting on you!

Resources

• WPC Website (ANSI guides):• www.wpc-edi.com• CMS Website:• http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp• EDIFECS Website:• http://www.edifecs.com/products/core_products/xengine/• ICD10 Website:• http://www.icd10watch.com/blog/7-benefits-hipaa-5010

Questions?