With ever-increasing margin restrictions, providers should be as prepared as possible for the potential of various 5010-related payer rejections affecting cash flow. There are various causes and types of possible 5010-related payer rejections that providers could encounter.

Payers have been interpreting 5010 guidelines in a variety of ways. In many instances, payors have rejected claims for reasons not identified during 5010 testing because of their specific interpretations of the 5010 Technical Report Type 3 (TR3) guide. Monitoring rejections and continuously working with payer mix is critical to providers in understanding and adapting to the differences in the payors’ specific interpretations.

Top 7 Reasons for 5010 Payor Rejections

MedAssets has identified the most common 5010 payor rejections during testing for both Institutional and Professional claims. The graph below provides insight into the cause of these payor rejections, as well as the suggested steps MedAssets has identified to resolve them:

1. Billing Provider Address

Applies to	Institutional and Professional claims
Description of change:	The billing provider address will no longer be allowed to contain a lock box or a post office box address. Instead, the billing provider address must be a physical street address which is associated with the provider’s NPI.
Provider Action	MedAssets has ANSI 5010 Syntax edits that do not allow claims to have addresses that are not a physical address. These edits cannot be bypassed to prevent our clients from experiencing this rejection type. It is advised that clients correct their patient accounting system(s) and claim maps to send the physical address associated with the NPI. If a client is unable to change its patient accounting system to comply with this critical 5010 requirement, MedAssets can complete these fields via bridge routines. Clients requiring assistance should work with their Account Manager to make this change as soon as possible. Clients that still wish to send P.O. box or lock box addresses can make the change today to send that data in the Pay-To-Provider field.

2. 9 Digit Zip Code Requirements

Applies to	Institutional and Professional claims
Description of change:	The new 5010 transaction set will require a nine-digit zip code for both the Service Facility and Billing Provider location only when the addresses are in the United States or Canada.
Provider Action	MedAssets has implemented ANSI 5010 Syntax edits that require nine-digit zip codes for both the Billing Provider and Service Facility per the X12 5010 ANSI TR Documents. If possible, clients should make the change to send valid nine-digit zip codes for these fields to avoid working edits and impacting clean claim rates. Clients can work with their Account Manager to create bridge routines if the patient accounting system is not able to support this requirement. It is important to note that the zip code must be a valid zip code and not simply meet the length requirements.

3. Type of Admission

Applies to	Institutional claims
Description of change:	Previously only required for inpatient visits to indicate the source of admission for the patient, the type of admission will now be required on all Institutional claims. The definition of this required data has changed in the 5010 transaction set to represent Priority (Type) of Admission or Visit. Clients that elect to send the values will not have these global routines impact their claims.
Provider Action	MedAssets has deployed a universal bridge to help address this issue for clients unable to send the data from their patient accounting system. Clients that elect to send the values will not have these global routines impact their claims.

4. Provider Assignment Codes

Applies to	Institutional claims
Description of change:	Formerly this code was a situational requirement used primarily for Medicare claims. In the 5010 transaction set, the completion of this field is now a requirement for all payors. The following values will be the only values accepted after December 31, 2011: A = Assigned B = Assigned on clinical lab only C = Not Assigned Clients that elect to send the values will not have these global routines impact their claims.
Provider Action	MedAssets has deployed a universal bridge to help address this issue for clients unable to send the required data. Clients that elect to send the values will not have these global routines impact their claims.

5. Accommodation Rates

Applies to	Institutional claims
Description of change:	In the 5010 transaction set, the accommodation rates sent in the SVD206 field have been eliminated. This change has an impact on our clients both for down-conversion and for ongoing support of paper claims.
Provider Action	MedAssets has deployed a universal bridge routine to populate the Accommodation Rates field (if not already present) for all claims stored within Claims Management (XClaim). This action will assist our clients to avoid rejections while continuing to support the paper claims requirement as defined by the NUBC. Clients can continue to send the values; however, if the values are not included, the routine will populate the rate field for the accommodation revenue codes on inpatient claims. Please note that MedAssets will not transmit this value on outbound 5010 claims. Its presence will aid our clients in meeting the compliance requirements for UB-04 claim formats.

6. Signature Source

Applies to	Professional claims
Description of change:	Previously used to indicate how and what type of signatures are on file for a patient, this field in the 5010 transaction set will now be required when a signature was provided on a patient’s behalf.
Provider Action	In the 5010 transaction set, the signature source is required to be P when the Release of Information = Y. Valid values for the Release of Information are either I or Y. If not the prior condition, then this field can now be blank. MedAssets has ANSI 5010 Syntax rules that will address both invalid values and required combinations. To assist our clients with compliance and to minimize the impact on clean claim rates, MedAssets deployed a Global MedAssets bridge routine as follows for clients that continue to send values that are no longer valid.

7. Insurance Type Code

Applies to	Professional claims
Description of change:	In the 5010 transaction set the requirement for this data has changed from being required to being required when the payor identified when Medicare is not the primary payor or is labeled under Other Payor Information. If clients continue to send invalid values in this field, MedAssets is prepared to assist.
Provider Action	MedAssets has deployed a universal bridge to help address the issue of invalid values or incorrect usage.

MedAssets began transitioning to 5010 production in advance of the December 31, 2011 compliance date based on payor acceptance testing and readiness. The transition period provided insight into specific issues unique to a live 5010 environment. Below are some of the issues specific to the 5010 production environment that have been discovered as payors made the transition to 5010 in production.

• In general, payors may reject claims and potentially deny line items that you may not expect. MedAssets is working with production 5010 payors to review rejections, RTPs, and denials and is building payor-specific edits on behalf of our clients as needed. Providers should monitor Edit Advisories closely for changes.
• Due to the late introduction of the 5010 Errata changes in October 2010, covered entities were required to revisit and build the 5010 Errata versions. Most payors did not start testing on the Errata versions until earlier this summer. Of those in testing, most payors tested claims only and had not yet begun testing ERAs, Eligibility, or Claim Status. As a result, providers may experience rejections at the claim level or batch level because production adjudication yields results that testing could not identify.
• Production claims provide visibility into second level 5010 requirements which may not clearly define the codes or the situations applicable. Second-level 5010 requirements are not made public via published payor companion guides. Edit application may vary in severity and location based on payor adjudication. The rules severity may be defined by the adjudication responses by payor.
• Invalid rejections have also occurred because of the processing issues experienced by our Partner clearinghouses. If you notice any rejection patterns please notify your Account Manager.