5010 Newsletter
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Though many within the industry have been using 5010 transactions for nearly four months, a handful of issues are still consistently causing the majority of claim errors and rejections. This is not a casual observation. It's drawn from data compiled during recent 5010 question and answer sessions hosted by the Centers for Medicare & Medicaid Services (CMS), as well as items listed on the claims processing issue logs at Medicaid Administrative Contractor (MAC) websites. Below are some of the top issues:
5010 production authorization—Many providers assume that once they pass the 5010 transaction tests at their clearinghouse, MAC, or commercial payer, that they are automatically moved into production. This is typically not the case. Most entities require providers to submit a "provider submitter change form" or re-enroll their organization to begin sending claims in the 5010 format. Providers that do not submit a change form (or re-enroll) and begin electronically submitting claims in the 5010 format may have their claims rejected and receive the following error: "Submitter not approved for electronic claim submissions on behalf of this entity."
Using clearinghouses for 4010A1 to 5010 conversion—Many providers generate 4010A1 claims and have their clearinghouse convert into the 5010 format. However, there are new data requirements in the 5010 format, and clearinghouses are unable to insert that additional information to claims if they don't have it available. For example, providers either need to have the following information in their 4010A1 claims (when there is a field for it) or provide their clearinghouses with the information so it can be added to the claim during 5010 conversion:
- Nine-digit ZIP code (Note: CMS has authorized clearinghouses to insert the value "9998" into the last four digits of the ZIP code when a five-digit—instead of a nine digit—ZIP code is supplied on the claim. Check with your clearinghouse if it is automatically adding the 9998 value into the last four digits of a five-digit ZIP code.)
- Physical address for billing location instead of P.O. box or lock box
- NPI identifier instead of tax ID number or social security number
- Numerous other issues listed in the following document
Become aware of widespread issues with clearinghouses and MACs before contacting support—MACs provide up-to-date issue logs that can be accessed online. These logs detail issues that are preventing claims and other transactions from reaching their destination. When a problem is encountered, check these logs first instead of spending valuable time on hold with customer support. The following are websites for the nation's MACs, which have sections devoted to listing current 5010 issues:
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Finally, provider organizations should closely monitor claims now and for several months after the mandated 5010 enforcement period, which began April 1, 2012. Providers should examine their rejections at the EDI level and through the remittance advice (EOB) that they receive. Doing this will help providers track the progress of claims, identify issues early, and address issues early to avoid reimbursement delays.
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