Electronic Billing Changes from 4010 to 5010

To accommodate the new electronic billing changes from version 4010 to 5010, Prime Clinical has already tested and passed the first phase of 5010 testing. PCS will continue to test and will be ready for release of the 5010 in the 3rd Quarter of 2011.

In the following information, Palmetto GBA answers some of the most common questions about their version-4010-to-version-5010 update and provides pertinent links:

Why Change to ANSI v5010?
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 included the Administrative Simplification provision. This provision required the Department of Health and Human Services (HHS) to adopt national standards for electronic health care transactions and code sets, unique health identifiers, and security. With the increased use of electronic transactions in the use and exchange of private health information, Congress implemented certain protections and standards safeguarding the 'confidentiality, integrity and availability' of an individual’s Protected Health Information (PHI).

The current standard for electronic healthcare transactions is the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12 version 4010A1. The ANSI electronic healthcare transactions applicable to Medicare include the following:

Over time, v4010A1 of these ANSI transactions have become widely recognized as lacking certain functionality that the health care industry needs. On January 16, 2009, HHS published rules allowing for the adoption and implementation of updated ANSI version 5010 for claims, patient eligibility inquiries, referrals, enrollment, coordination of benefits (COB) and remittance advices.

What is ANSI v5010?
ANSI v5010 will result in the new framework for electronic transactions submitted to Medicare and is necessary for the health care industry’s transition from the use of ICD-9-CM coding to ICD-10 in 2013. Nationally, over 99 percent of Medicare Part A claims and over 96 percent of Medicare Part B claims transactions are received electronically. In order to continue the successful submission of electronic claims, providers must prepare for the ANSI 837 v5010 transition. Full compliance with ANSI v5010 is required by December 31, 2011.

What are the Benefits of ANSI v5010?
Providers will find several improvements with ANSI v5010. The benefits of converting to v5010 include:

• Less ambiguity in the Technical Reports Type 3 (TR3) guides (i.e., implementation guides)

• Enhanced usability of certain transactions such as referrals and authorizations

• Reduced reliance on companion guides

• Supports increased use of Electronic Data Interchange (EDI) between covered entities

• Supports e-Health initiatives

What are the Enhancements with Version 5010?
Enhancements associated with ANSI v5010 will include:

• Improved claims receipts, control and balancing

• Increased consistency of claims editing and error handling, which will provide common edit definitions that will be used by all

• Returns claims requiring correction earlier and assigns claim numbers in the front-end

• Allows for the necessary modifications (e.g., increased field sizes) needed for the transition from ICD-9 to ICD-10

When Will These Changes Affect You?
To help with transition preparation, key events in the implementation timeline are shown below:

Source: CMS ICD-10 and Version 5010 Compliance Timelines

Being prepared is vital to a successful ANSI v5010 transition. Prepare now by taking the following actions:

• Contact your system vendor

• Schedule your upgrade before January 1, 2012, to include new standard acknowledgement and rejection reports:

• • TA1 for rejected interchanges

  • 999 transaction, which replaces the Functional Acknowledgement 997

  • Claims Acknowledgement (277CA), which replaces proprietary error reporting

• Evaluate the impact to your routine operations

• Plan for training your staff

• Plan for implementing the changes

How Can I Find Out Additional Information on ANSI v5010?
In upcoming months, Palmetto GBA will issue additional articles and educational tools regarding the transition to ANSI v5010. Information about ANSI v5010 is also available through the CMS Web sites:

• Latest v5010 news for all HIPAA covered entities

• Side-by-side comparison of current and new transaction formats

• Electronic billing and EDI

• HIPAA Eligibility Transaction System (HETS)

• Information on ICD-10-CM and ICD-10-PCS

• Official CMS educational products and information for Medicare fee-for-service (FFS) providers
  

If you have any questions regarding this information, please contact our EDI department by phone:

• Jurisdiction 1 MAC, Jurisdiction 11 MAC, South Carolina Part A, South Carolina Part B, RHHI, and Railroad Medicare: (866) 749-4301

• Ohio and West Virginia Part B: (866) 308-5438

Palmetto GBA, LLC