Commentary: How HIPAA 5010 has fared thus far

By Debbie Meisner
09:57 AM
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The Jan. 1, 2012, implementation deadline for conversion from ASC X12 4010 to version 5010 claim submission standards came and went with sighs of relief: providers and health plans alike were granted a reprieve from enforcement by the Centers for Medicare and Medicaid Services (CMS). But that doesn’t mean we can sit back and relax: the new CMS enforcement date of June 30, 2012, is approaching rapidly.

Like any other technical change, the 5010 conversion hasn’t been rosy for many providers. For example, the American Medical Association (AMA) received many reports from its members claiming disruptions in their cash flow from claim submission glitches. Other AMA member physicians expressed concerns that claim status reports were not being distributed in a timely manner. These issues, and others, led CMS to push out the enforcement date.

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But, in spite of the glitches, progress toward 5010 conversion continues. Organizations using the 5010 standards are already realizing its advantages. Providers are benefitting from a system that was designed to add consistency to processing, will prove more useful for certain transactions such as referrals and authorizations and is easier to navigate. The 5010 standard also supports emerging e-health initiatives by encouraging greater use of electronic data interchange (EDI). But perhaps the greatest benefit of the 5010 conversion is that it lays a valuable technical foundation for the upcoming ICD-10 transition, a change could be far more disruptive for the industry.

Physicians who are behind the implementation curve should be wary of rejected transactions and the possibility of penalties from CMS. If you are a direct submitter to Medicare and have not yet tested 5010 Medicare transactions, be advised that you need to submit a transition plan to your Medicare contractor. If you are submitting Medicare claims via a clearinghouse and are not yet submitting in the 5010 standard format, check with your clearinghouse to ensure they are prepared to accept claims in non-standard formats and convert them to the 5010 standard.

Most payers are transitioning to 5010 in a sequential manner, beginning with claims transactions, moving on to electronic remittance advice (ERA) and then eligibility and other real-time transactions. Therefore, transition timelines vary not only by payer but also by transaction type.

It’s understandable that some healthcare organizations may be behind when it comes to 5010 compliance. For example, the Errata issued by ASC-X12 late in 2010 caused some delay by requiring significant changes from both payers and providers. So, if you’re still navigating the 5010 conversion, know that many valuable resources are at your disposal. For the most part, EDI vendors have risen to the challenge of ensuring that their services have been enhanced to facilitate the new transaction standards and are providing an implementation roadmap to help providers navigate the transition. Some companies are even sharing in-depth gap analyses for all supported transactions to customers.

After your organization implements 5010 — if it hasn’t already — you can experience the benefits of the improved 5010 transaction standard: streamlined referrals and authorizations, cleaner processing and user-friendly navigation. And, perhaps most significantly, your organization will also be more prepared for the upcoming transition to ICD-10.

Debbi Meisner is the vice president of regulatory compliance strategy for Emdeon. She also sits on the EHNAC Board of Directors, the WEDI Board of Directors, is a co-chair for the Health Care Task Group of ASC-X12 Insurance Subcommittee and a liaison for the National Uniform Bill and Claim Committees.