For more information on how you can learn more about the changes to the transaction sets, please consult these industry resources:
CMS 5010 Info & Education links to http://www.cms.gov/home/regsguidance.asp
5010 is the newest version for ANSI X12 data. It will replace the 4010/4010A1 version. The updated X12 Version 5010 of the HIPAA transaction standards represents substantial technical and operational improvements that respond to industry business needs and requests. With the transition to Version 5010, the industry will be better equipped to move toward an electronic health information environment via the increased and improved use of Electronic Data Interchange (EDI). The compliance date for Version 5010 is January 1, 2012. The use of Version 5010 supports ICD-10-CM (Clinical Modification) for diagnosis and ICD-10-PCS (Procedure Coding System) for inpatient hospital procedure code sets that have been adopted in a separate regulation. The compliance date for ICD-10 conversion was October 13, 2013. CMS announced in early 2012 that it plans to postpone the deadline and will announce a new compliance date in the future.
The following transactions are included in the 5010 Final Rule:
- 837 – Health Care Claims for professional, institutional and Dental
- 835 – Health Care Remittance Advice
- 270/271 – Health Plan Eligibility Inquiry and Response
- 276/277 – Health Care Claim Status Request and Response
- 278 – Health Care Services – Request for Review and Response
- 820 – Health Plan Premium Payment
- 834 – Health Plan Enrollment and Disenrollment
- NCPDP D.0 – Retail Pharmacy Drug Claims
Benefits of ANSI 5010:
- Increased transaction uniformity
- Support for pay-for-performance
- Streamlined reimbursement transactions
- Support for ICD-10-CM codification
If you have questions, we’re here to help you, so please contact your MedAssets Account Manager or e-mail us directly at email@example.com.
5010 Provider Readiness Checklist
- Identify changes to data to accommodate the 4010 to 5010 key changes
- Identify your portfolio of systems and vendors to understand the full impact of 5010
- Update workflow and business processes
- Identify staff training needs and build a training plan
Claim Transaction Readiness
- Import claim files for testing
- Review and adjust your claim file for optimal results
Payor and Vendor Readiness
- Understand payor and vendor implementation timelines
- Plan resources accordingly
- Review payor-specific 5010 edits
There are several key changes your organization should be making now to achieve a successful transition.
Identify changes to data to accommodate the 4010 to 5010 key changes
While the intent of 5010 is to streamline and improve the communication of vital data in the HIPAA EDI transaction sets, the new transaction set differs in many ways from 4010. Some fields were eliminated and new fields were added. Some of the key improvements delivered by the 5010 set version include: minimizing ambiguity, eliminating redundancies, closing 4010 loopholes and minimizing the need for trading partner companion guides.
Providers will want to conduct a gap analysis comparing their specific 4010 transaction sets to those of 5010 to better understand the organizational impact. For more information, review the ASC X12 Change Description 5010 Consolidated Guide for complete content from the mandated 5010 documents, all of the segments from 004010A1 and a description of the changes.
Identify your portfolio of systems and vendors to understand the full impact of 5010
In most hospitals and health systems, multiple software systems will be impacted by 5010. Systems include patient accounting systems, claim scrubbers, billing services and any proprietary systems that incorporate data files from the HIPAA transaction set (such as the professional and/or institutional 835 or 837). At a minimum, a new software version would simply be installed or, in the case of Software-as-a-Service, upgraded. Updating these systems may require vendor coordination by both billing offices and IT departments. Work with your IT department to create a system impact list detailing the impacted systems and an action plan to move them to 5010.
NOTE: MedAssets Claims Management software is ready.
MedAssets completed its 5010 Level 1 compliance testing for its Claims Management solution in December 2010, and has since deployed 5010-compliant XClaim version 8.1, including Errata changes, to all clients. Level II compliance testing with providers is underway (See testing section below) and is required to complete the conversion from 4010 to 5010.
Update workflow and business processes
MedAssets has identified many changes for 5010 that providers should address to avoid any unexpected claim rejections in the 5010 environment. These items include: changes to key fields, including Billing Provider and Service Facility Addresses; Pay to Provider; Patient Status Code; Priority or Type of Admission, and more.
Identify staff training needs and build a training plan
Your staff needs to be trained to make sure transactions are correctly submitted, received, interpreted and responded to using the new 5010 transaction set. Managers should understand the basics of the 5010 set and what needs to be done to comply with the new regulation. In determining where to start, training staff on changes to workflow and business processes necessitated by the new 5010 format should be a top priority. By identifying your organization’s training needs and building a plan to support it, your team will be better positioned to support a smooth transition to 5010.
Claim Transaction Readiness
Import claim files for testing
MedAssets continues to work with our clients to import 5010-ready claim test files for our 5010 Quality Assurance team to review, compare and perform testing to 5010 standards.
Review and adjust your claim file for optimal results
MedAssets goal for client 5010 testing is to help clients achieve 5010 compliance and validate that their organization has the ability to keep a clean claim rate in a new 5010 environment similar to the existing clean claim rate in production. Specifically, the 5010 provider testing process addresses those items that cause edit issues and rejections.
Payor and Vendor Readiness
MedAssets has established a dedicated 5010 Payor Testing team that is committed to testing with our payor network on our clients' behalf. This team is charged to enable our clients to focus on their internal 5010 readiness needs, such as establishing compliant billing practices and conducting patient accounting system testing. Since MedAssets is conducting this level of payor testing, it is not necessary for clients to plan to conduct transactional testing with each individual payor.
Plan resources accordingly
As with any major system change, providers will want to verify the accuracy of payor transaction processing and will want to closely monitor claim processing and production of the remittance advice with payors.
On behalf of our clients MedAssets will continue to monitor and verify that all claims processed are submitted and reconciled in a timely manner. MedAssets also will continue to pursue actively any missing remits and partner with our providers to create reporting and views into the claim adjudication process via various tools in Claims Management.
Review payor-specific 5010 edits
As part of our ongoing payor testing process, payor-specific rule changes will be communicated via edit advisories to MedAssets clients. Look closely for edit advisories specific to your payor mix to make you aware of the latest rules changes for the payors that are most important to your revenue cycle. It is very important that our clients understand that MedAssets has not yet received published companion guides from some payors and trading partners to support our clients' ability to test all payor edits. It is also important to note that only deviations from the standard Syntax rules will be reflected as payer-specific 5010 modifications. We continue to work aggressively with payors to identify certain items and rules required for a successful transition.
In addition, as payors and providers each approach transitioning to 5010 in their own unique timing, MedAssets is able to up-convert and down-convert transactions from 4010 to 5010, and vice-versa.