August 2011 Newsletter
The ANSI 5010 Transition - Where We Stand
With less than five short months remaining, the transition date of January 1, 2012 to the ANSI 5010 format is fast approaching! Below are the notable updates, notifications, and changes pertaining to the ANSI 5010 transition.
We are pleased to announce that we have been certified by Emdeon to submit UB claims in the ANSI 5010A2 format. We continue to submit test files for 1500 claims and are confident we will also be approved shortly. Emdeon indicates that it would like to be in 5010 Production sometime in September. To date, Quadax has been approved to submit UB claims in the ANSI 5010 format by 21 out of 86 payers, and we are in active testing with 21 other payers, accounting for nearly 50% of all payers to whom we submit claims! We will continue 5010 testing with the remaining payers based on individual payer requirements outlined in their associated Companion Guides, once they are published.
On June 21, Quadax received word from multiple sources that CMS experienced issues with its processing system that effectively prevented MACs from approving entities to submit Institutional Medicare claims in the 5010 format. The issue also negated all previous testing conducted by Quadax EDI with the various state Medicares/MACs. (Quadax began testing with Ohio Medicare as early as April 5.) Three days later, NGS informed us that CMS would institute the necessary corrections around July 4. On July 20, we received confirmation from WPS (MAC J5) that the fix was implemented “around July 5.” However, each MAC must still implement the fix to update its claim processing systems, which will most likely delay the necessary retesting process. Ultimately, Quadax will have to resend test files to each Medicare/MAC once the fix is in place, before any of the Medicares/MACs will approve us to submit Medicare claims in the ANSI 5010 format. Despite this delay, Quadax submitted its first “live” 5010 Production file to Nebraska Medicare in early August!
During our testing with MI Blue Cross, the payer indicated that the LOB (Line of Business, a.k.a. Payer Type Code) will be different for Federal Employee (FEP) claims submitted in the ANSI 5010 format. Instead of an “OF” LOB, which is currently used for this payer in ANSI 4010, BCBSM will be expecting an “FI” LOB Code for FEP claims submitted in the ANSI 5010 format. Quadax strongly recommends that clients submitting these types of claim make the necessary adjustments to their HIS to accommodate this new payer requirement.
Based on ANSI 5010 testing with multiple payers, Quadax continues to identify a large volume of UB test claims from providers that contain the two most frequent errors that cause UB file rejections:
- A 5-digit ZIP code is provided rather than a 9-digit ZIP code in the Billing Provider Address (FL 1).
- A P.O. Box or Mail Drop address is provided in the Billing Provider Address (FL 1), which is permitted only in the Pay-To Address (FL 2).
Quadax reminds our clients that these are mandatory changes for the ANSI 5010 format and that a provider’s claims will not be transmitted once a payer has been transitioned to a 5010 Production status. We strongly encourage our clients to make the necessary changes a soon as possible to ensure that ANSI 5010-appropriate information is provided in both test claims and 5010 production claims.
Quadax has learned that Highmark EDI completed ANSI 5010 testing and proposed transitioning to 5010 production at the end of July 2011. Knowing that this transition may negatively impact some of our Freedom Blue, WV Blue, and PA Blue submitters, a "5010 Readiness" forum thread titled "Highmark Blue Cross is Ready to Accept 5010 Claims" has been created for Quadax EDI Services clients. We welcome your thoughts/concerns within the forum regarding this matter. To visit the forum, please log on to the Portal, click on the Community tab, and access the Forums page.
As a reminder, the 5010 format is able to support the Taxonomy Code at both the Group and Physician level. Taxonomy codes are tied to the NPI entry in the Quadax Client setup database. For physician claims, if the Group indicator is set as “1” in our database, then only the Group taxonomy code will be sent in the outbound 837P. If it is set as “2,” then both the Individual (Physician) and Group level taxonomy codes will be sent. If the Physician level taxonomy is blank (i.e. not provided/set up), then the Group level taxonomy code will be copied and sent as both the Group and Individual (if required by the payer), since the Group and Physician level codes can be the same. If both the Physician and Group level taxonomy are provided, but the Physician level taxonomy code is not needed by the payer, it will not be sent.
Based on Technical Direction Letter (TDL) 11378, the Entity Identifier Code (EIC) of "PE" (Payee) will be replaced with "87" (Pay-to Provider) on physician claims. These changes will be formally documented under CMS Change Request (CR) 7515 in January 2012; however, MACs have been instructed to make the changes and implement them by July 31, 2011. For additional information, please reference page 11 of the CMS Matrix - 5010 A1 837/276 Requirements document.
The Subworkgroups of the Transactions and Code Sets Workgroup have prepared educational materials and resources to assist the medical industry as it moves toward the final stages of implementing the ANSI 5010 transactions. To help the industry utilize the materials, a document has been created listing all of the resources that are available or are under development. To view the listing, go to the WEDI SNIP Transactions Workgroup Resources Spreadsheet in the “What’s New” section of the WEDI website. Note that a profile with a username and password is required to view this document.
New York Medicaid notified providers that from July 21–December 31 it will accept both ANSI 4010 and 5010 formatted claims. Starting January 1, 2012, it will accept 5010 formatted claims only.
To foster a better understanding of MAC testing protocols and the transition to Version 5010, CMS recently announced a National Version 5010 Testing Week, August 22–August 26. Both Quadax and CMS encourage all trading partners to participate. Additional details concerning transactions to be tested will be forthcoming from your local MAC.