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Checking the pulse of 5010

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  By Jackie Griffin,  February 13, 2012

In the next month or two, almost all providers can expect to see claims held up due to rejections from the 5010 claims transition. Here are some tips to help you get over the most recent industry hurdles.

There is absolutely no denying it now — 5010 is here, and we're all feeling the weight of it. Over the past few weeks, I've been presenting on 5010 with associations and talking with representatives from all different areas of the industry to get a feel for the main points of pains that are out there.

What I've found is that, whether or not your practice has transitioned to 5010, most likely you've been facing an increased number of rejections. We knew that everyone that touches medical claims would deal with issues during a transition of this size, but many people were not ready for an impact of this magnitude. Providers, PMS vendors, clearinghouses and payers are all experiencing challenges processing claims in 5010, and as a result of that, your claims are being delayed.

Here are three common issues I've been seeing:

1. File acknowledgement reports
5010 changes the way claims are formatted, which also changes the format of the reports payers send back, such as the file acknowledgement report (999) that notifies us when the payer has accepted or rejected your claim. We're finding that payers are implementing the use of acknowledgement reports in different ways, resulting in more rejections at the 999 level. We are seeing claim files rejecting at the 999 level for reasons such as an unrecognized provider identifier or invalid member ID, for example. These types of issues result in immediate delays in claim processing. Identifying and correcting these issues for each payer has been time consuming for clearinghouses. We are working closely with all payers to resolve issues as timely as possible.

2. Payer transitions to 5010

Migrating all insurance companies over to the new 5010 format was challenging. Some began moving to 5010 without informing their trading partners, or they failed to make the switch to 5010 on the date they originally planned, leading to claims getting stuck unexpectedly. While your billing partners can resolve these issues, it can take several days to uncover and address these hold-ups.

3. Interpretation of standards
While 5010 establishes standards for coding, the way people are interpreting these standards is not always consistent. When payers interpret standards for claims differently than the provider or biller who submits them, the claims will be rejected. If your clearinghouse knows how the payer is applying the standards, it can identify any discrepancies in your claims and provide direction on which areas to address before submitting the claim to the payer. Since the industry is still in the beginning stages of the transition, we are all still learning and trying to understand how each entity has interpreted and implemented the new standards. During this time, you will see an increase in rejections that will impact your cash flow.

What can you do?
If you haven't already felt the impact of these challenges, you will. In the next month or two, almost all providers can expect to see claims held up due to rejections. Here are some tips to help you get over the most recent industry hurdles:
    Know what new claims data is needed for the 5010 format. While your PMS vendor or clearinghouse can help convert your claims to meet 5010 compliance, we can only work with the data your practice provides. If new requirements, such as the nine-digit zip code and billing provider address, are not submitted at all, your claim cannot be converted and sent. For examples of what new data is required, you can visit the CMS website here.
    Monitor your rejections both at the EDI level and in your remittance advice (EOB), where claims are adjudicated at the payer. This will help you track the progress of your claims and identify and address issues early to avoid delays in your reimbursement.
    Network with other practices in your specialty to learn what challenges they have encountered and how they are resolving them.
    Check out what industry associations are saying about the transition. They can give you notice of industry-wide challenges, as well as recommend ways to operate more efficiently in 5010.

While times seem dark, remember that we have experienced this level of industry change before with the transition to 4010 and to NPI, and as with those transitions, the industry got back on its feet after a few months of working through the kinks.

About the author
Jackie Griffin is client services director at Gateway EDI. For more tips on 5010, visit www.gatewayedi.com/5010.


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