Preparing for 5010 Errata – Deadline 1/1/2012

Everyone should know that major changes are coming in electronic claims filing.  The hard cutoff date for any 4010A1 claims to be accepted is 12/31/2011 and effective 1/1/2012 all electronic claims must be filed using the 5010 format.  The 5010 format was updated to 5010 Errata (correcting some transaction and HIPAA issues) and will be ready for testing with external entities in April 2011.  So, why worry about this in January, 2011?  It is widely known that the 5010 format is required to support the ICD-10 coding changes.  However, with all the focus on supporting ICD-10, you may be missing some important changes that may require you to collect and report additional information.  A quick review of the professional claims requirements could identify some less publicized changes that may impact your business processes.

• National Provider Identifier (NPI) – Mandated that the same NPI be on all carrier claims for a service.  Review your NPI structure to make sure it is meeting your needs.
• Billing Entity – Must be a health care provider and the Billing Address must be a physical address (no PO Box).  New Pay-To fields will be used for lock box and other types of payment arrangements.
• Service Facility – To be used when subparts of the Billing Entity are not separately identified.
• New segments specific to Anesthesia Related Procedures, Obstetric Anesthesia Additional Units, and Line Supplemental Information.
• Patient/Subscriber Restructured – Anyone with a unique ID is considered the subscriber; a child with a unique health care plan identifier (for Medicaid or commercial insurance) is considered the subscriber.

If you have not already started planning with your billing and payment partners, now is the time to start.  Clearing houses/payers may not be following the same CMS format and may require additional information or changes.  There will also be changes in the Electronic Remittance Advice (ERA) and many clearing houses/payers are not including the flow through the systems back to you in their testing.  It is recommended that you plan testing with your billing and payment partners as early as possible to allow time to correct any problems found.  Now is the time to create your plan to reduce your risk of delays in filing claims and posting electronic remittances in January 2012.