Answers to 5010 FAQs

General 5010 FAQs

Version Questions

Send Medicare in ANSI 5010

Send Via Clearinghouse or Other Direct Pay in ANSI 5010

Set Up Information

Addresses

General Billing and ERA Questions

Zip Code Issues

ICD10 Code Issues

General 5010 FAQs

Version Questions

What version of the program supports ANSI 5010?

Answer: OnStaff (UNIX) 02/22/2012 and after
Intellect (Windows Version) 9.12.29 and greater

If I’m on a 5010 version but not on the latest version, do I need to re-send all my claims?

Answer: Unless you have received rejections on the 999 or 277CA reports, there is no reason to resubmit claims.

Is the 5010 UPDATE included in our Software Maintenance or do we have to pay for the update?

Answer: If you have Support Maintenance, the 5010 Update is included. If you do not have a current maintenance agreement, send an email with your client ID, Client Name, Contact Person name, and Contact Number to accounting@primeclinical.com. You will be contacted in the order the email is received.

Can we still bill in 4010 format, and when is the cutoff for 5010?

Send Medicare in ANSI 5010

The 999 Report is saying: LOOP 2310 NM1 IMPLEMENTATION DEPENDENT NOT USED SEGMENT. What does it mean and what do I do?

Answer: This message is due to a Referring doctor that is not necessary for a particular claim. Medicare is a lot more strict as to whether a Referring Provider is needed or not.
In Intellect, remove the Referring doctor and re-transmit the claim.

What is the first thing I need to do to send 5010 claims?

Answer: You must first get Medicare production approval. Refer to the information we have on the News site; i.e., In Intellect, select menu option Help, then select News. In OnStaff 2000, do Ctrl/E, select Prime news. Click on 5010, and look for items related to medicare production approval.

I have received Medicare's production approval for ANSI 5010. What is the next step?

• Intellect (Windows version): (1) Make sure the version is 9.12.29 or greater, (2) Change the version in Utility/Insurance/Tele Com as needed; i.e., Part A Institutional 005010X223A2 or Part B Professional 005010X222A1.

• OnStaff (Unix version): (1) Make sure the version is 02/22/2012 or greater, (2) Change the version in Utility/Insurance; i.e., type in the appropriate code for either Medicare or Medi-Medi insurance.

• Both Intellect and OnStaff 2000: Make sure you have read and updated the information in our emails regarding addresses with a P.O. Box, Clinic, Provider, and Facility Zip Codes with 4-digit extensions, confirm all Provider, Referring, and Facility records have the NPI completed.

Do I also need to make the change for the VERSION number in the Utility/Insurance for Medicare?

Answer: Intellect: No, only in the Utility/Insurance/Telecom Screen.
OnStaff: Yes.

Send Via Clearinghouse or Other Direct Pay in ANSI 5010

When can we start sending 5010 claims?

• Intellect (Windows): Any version > 9.12.29 is 5010 compliant. (9.12.18 was the first 5010 version released, though changes have been made, and PCS recommends everyone updates to version 9.12.29 or greater).

• OnStaff 2000 (UNIX): Any version > 8.2 (released 09/25/2009) is 5010 Complaint.

Do I need to do anything other than update my system?

Answer: Yes. After you have updated to the ANSI 5010 version , you will need to update the Utility/Insurance/Tele Com screen's <Version> field to the 5010 version:

Do I also need to make the change for the VERSION number in the Utility/Insurance for all my insurances?

Answer: Intellect: No, only in the Utility/Insurance/Telecom Screen.
OnStaff: No, only for the Insurance code used for Electronic Billing.

Set Up Information

Do I need to add the 'Principal Procedure Code' in the Encounter screen?

Answer: In accordance to the 5010 Specs for Institutional Type Electronic Billing on Out Patient claims, you do not need to add the 'Principal Procedure Code' in the Encounter screen. You should post the procedure as you would any other procedure through the Charges Menu.

In ANSI 5010, do I need to have NPI SUPPORT set to 'X'?

Answer: Yes. If it is set up to any other values, all your claims will be rejected.

What happens to the HCFA 1500 if I set the <Group Y/N> field to N in Utility/Provider?

Do I need to have a Taxonomy code in the Utility/Referring table?

Answer: The Taxonomy Code is NOT required for 5010, however, some payers may require it since the Taxonomy Code is specialty appropriate. If the Taxonomy Code is needed:

• OnStaff (Unix version): Use [F2] to select the right option, or type in the correct code.

Addresses

I have the word BOX in my Provider and Clinic address, although the address is not a P.O. Box, is that OK?

In Intellect's 9.12.24 version, the software corrects the patient's zip codes. Can the software correct other tables such as insurance?

Answer: At this time, only the patient table will be updated. It is anticipated that other tables will be corrected in the future.

Does the address in Box 33 need to be changed from a P.O. Box if we are billing by Provider?

From Palmetto's Website: 5010 does require a physical address for the billing provider's location. Claims received with a P.O. Box in place of a physical address will receive an error.

Do I need to contact Medicare and update my address to the physical address because of the new 5010 P.O. Box changes for the billing provider?

Answer: Yes. Per Medicare, YOU MUST contact them/Palmetto and update your address on file. The contact center number to call is 1-866-931-3901.
If your address is NOT updated at Medicare, your claims will be rejected. See below:

ANSI 5010 requires providers to bill with physical addresses. A P.O. Box address is no longer accepted in the electronic equivalent of Box 33. To accommodate for providers who wish to continue receiving payments to a P.O. Box or other secure site, the ANSI 5010 has a Loop and Segment which was not part of the ANSI 4010 file. Effective version 9.12.26 Intellect has added the ability to transmit the ‘Pay To’ address when different than the physical address.

To implement the ‘Pay To’ address feature, complete the new pay-to fields available on the Utility --►Set Up --►Clinic and Utility --►Provider --►Provider screens - refer to the OnLine documentation for additional information.

o Complete the original <Address>, <Zip Code>, <City>, and <State> fields with the P.O. Box or other pay-to address.

o Complete the new <Physical Address>, <Physical Zip>, <Physical City>, and <Physical State> fields with your physical address.

o The pay-to address information will be submitted in Loop 2010AB Segment NM1, 87

o The physical address information; i.e., the <Physical Address> field, will be submitted in Loop 2010AB Segment NM1, 85

o Complete the original <Address>, <Zip Code>, <City>, and <State> fields with the physical address. Leave the new <Physical Address>, <Physical Zip>, <Physical City>, and <Physical State> fields blank.

o The <Address> field information will be submitted in Loop 2010AB Segment NM1, 85

This feature is available only in ANSI 5010; it is not available in ANSI 4010 claims submission.

General Billing and ERA Questions

I received the 277CA (Acknowledgement Report) but there are no patients listed. Why?

Answer: This could be caused by several things. First, make sure the <Name>, <Address>, <City>, <State>, <Zip Code>, and <NPI> fields are filled in Utility/Facility. Verify your provider is eligible to submit in ANSI 5010. Verify the Submitter Number is correct on the Insurance/TeleCom screen. If the above items are correct, contact Support so we can check additional set up on the Insurance/TeleCom screen: ISA Receiver Codes and ISA Sender Codes.

I am getting a CO-16 error on my EOMB. What should I do?

Answer: You have billed a CPT code(s) that requires a referring doctor (including self-referral). Proceed as follows:

• If it is a self-referral charge, add all your Providers in Utility/Referring and then attach the proper Referring Provider to the rejected charge in Charges/Modify.

• If it needs an outside referral, make sure the 'outside' Provider is set up in Utility/Referring and then attach the Referring Provider to the charge in Charges/Modify.

When a referring source is required and the rendering provider is the referring provider, do I need to have all the Providers set up in Utility/Referring?

Answer: If the rendering provider is the referring provider, you should add them in Utility/Referring. For the information to be transmitted electronically, or printed on paper, set the <Doctor/Other> field to D. This will populate the Referring information in Loop 2310A, Segment NM1. With ANSI 5010, clients are reporting rejections for diagnostics when the rendering and referring are the same and they had not entered the referring physician when posting charges. The EOB error codes are: "N285 Missing/incomplete/invalid referring provider name." and "N286 Missing/incomplete/invalid referring provider primary identifier." We do not yet know the 277CA rejection codes.

Do we have to test for 5010?

• If sending direct to Palmetto GBA, No. Prime Clinical is doing the testing for you, though you must first get Production Approval (as mentioned previously in the FAQs).

• If submitting via Capario, Gateway EDI or OptumInsight: No, testing is not needed.

• If sending via any other clearinghouse, direct to another payor or another Medicare Administrator - call them directly to ask if you need to test.

My claims are being rejected for an injury date not being submitted.

Since I am not on the latest version, do I need to re-send all my claims?

Answer: Unless you have received rejections on the 999 or 277CA reports, there is no reason to resubmit claims.

When we switch to 5010 billing, will we still be able to receive the ERA files automatically and are there any changes to the ERA files?

Answer: Prime has made the necessary changes to accommodate for ERA and Eligibility.

Will the 5010 affect my HCFA 1500 forms or UB forms? If so, how?

If we are using any Non-Specific Procedures; i.e., 90999, is there anything special required for 5010?

Answer: Yes. Be sure your Procedure includes an adequate 'Description' and that the following information in your Program is set up correctly:

• Intellect: Utility/Procedure/<Send Description> = Y (new field added in version 9.12.21)

Zip Code Issues

ENS/INGENIX is rejecting the claims because all the zip codes are padded with zero.

For physical therapy claims where the service is performed at patient's home (PS=12), does there need to be a 2310C loop with the patient's home address? If so, does it need a 9-digit zip code? (as of 12/16/2011)

Answer: When physical therapy is performed in the patient's home (PS=12), the patient's home address, including 9-digit zip code, must be included in loop 2310C.

Most of the patients' zip codes have been corrected. Why are there some that are still wrong?

Answer: The combination of the patient's address and zip code do not match the USPS database. Verify you have the correct house number and zip code. Is there an apartment or suite number? If it is missing or incorrect, the system will not be able to find a matching zip code with a 4-digit extension in the USPS database.

What tables need to have a 9-digit zip code?

Do I need to start adding a 9-digit zip code for each patient?

Answer: We have been told that it is not necessary at this time, but we anticipate that it will be needed in the future, so adding them now will get you that much farther ahead and will not affect your billing. The only situation we know of where the patient's 9-digit zip code is required, is when billing for services provided in the patient's home.

Can I begin adding the 4-digit zip extensions to other parts of my program? Are these extensions being accepted?

ICD10 Code Issues

Will PCS be loading the new ICD10 Codes?

Answer: No. YOUR OFFICE WILL NEED TO PURCHASE THE ICD-10 DISK from the AMA IN ‘A SHORT TEXT FORMAT’.

• Intellect: Has the capability for your office to import the ICD-10 codes.

• Unix: This version of your program DOES NOT HAVE the capability for you as a user to load the ICD10 codes, however, if your office purchases the codes in ‘A SHORT TEXT FORMAT’, PCS will invoice your office the cost for loading the ICD10 codes.

What should we being doing now for the new ICD10?

Answer: No action is required at this time. January 1, 2013 is the date you need to start using ICD-10.

Can we start using the ICD10 Codes?

When can I start to send my claims in ANSI 5010 format to my clearinghouse?

• OptumInsight (Ingenix/ENS): PCS has been informed that you can continue sending in ANSI 4010 and they will convert it to ANSI 5010. Or, you can go through their testing process if you wish to start sending in ANSI 5010 now. Contact OptumInsight for testing instructions.

When a referring source is required and the rendering provider is the referring provider; do I need to have all the Providers set up in Utility/Referring?