Delivering the Practice of the Future Now

What is ANSI 5010?

ANSI 5010 Medisoft Training- Quick Preview


ANSI 5010 Overview

On January 16, 2009, the U.S Secretary of Health and Human Services issued Final Rules for Updated Versions to the electronic transactions originally outlined under the Administrative Simplification Subtitle of the Health Insurance Portability and Accountability Act of 1996.

The rule requires that the current 4010A1 version be upgraded to new ANSI 5010 for health information transactions governed under HIPAA.

Important Dates

  • January 1st, 2011 - ANSI 5010 transactions start to be accepted (check with your clearinghouse)
  • January 1st, 2012 - All transactions must be in ANSI 5010 format

Summary of Changes within ANSI 5010

Claims

  • Separates diagnosis code reporting
  • Clarifies use of NPI
  • Greater consistency between dental and professional claims
  • Simpler COB requirements
  • POA indicater

Remittance

  • Clarifies rules for use
  • Eliminates "not advised" elements
  • Stronger balancing rules
  • Can be used with 4010 claims
  • New medical policy segment

Claim Status

  • Allows prescription number reporting
  • Eliminates sensitive information to satisfy privacy concerns
  • Instructions for batch and real time use

Eligibility

  • Mandates additional service types such as chiropractic, emergency services, pharmacy, vision and professional visits
  • Clarifies dependent and subscriber relationships
  • Requires alternate search support

Enrollment

  • Improves privacy protections
  • Adds additional information, such as enrollment subtotals and coverage reasons

Referrals/Authorizations

  • Provides specific information on conditions
  • Asks for number of occurences
  • Separates segments for key patient conditions
  • Supports and expands authorization exchanges

ANSI 5010 Compliance must be taken seriously.
Can your practice afford to lose $5,000? How about $25,000?

“As the date for compliance with the government’s updated standard for electronic claims transaction rapidly approaches, physicians need to have practice management software in place that meets those standards,” said the American Medical Association (AMA) President Cecil B. Wilson, M.D., in a joint statement released April 28, 2011 with the Medical Group Management Association (MGMA).

“In order to avoid cash flow disruption associated with the transition to the 5010 standard, it is critical for physician practices to convert their administrative systems and test their readiness well in advance of the compliance date,” added MGMA President and CEO William F. Jessee, M.D.

That’s the risk you run if you can’t submit claims in the upcoming ANSI 5010 (a.k.a. HIPAA 5010) electronic standard. Without the ANSI 5010-enabled billing software, experts warn you may see an increase in claim rejections. If you submit $500,000 in claims each year:

A 1% increase in claim rejections means $5,000 in lost revenue to your practice.
A 5% increase in rejections is $25,000 in lost revenue!

There are numerous fields missing from previous versions of your billing software that may be required in certain circumstances. Many of these fields are patient-specific.

Some clearinghouses may tell you that they can create a 5010- compliant claim from legacy inbound formats including 4010. This may be true. However, ask how they plan to handle the conversion. Will they hard code the missing data fields, and therefore make the data the same for all patients? Will they use blank fields such as box 10d to map the new fields? Where will the data come from if not from your medical billing system? How will this approach increase risk to your cash flow?

The American Medical Association (AMA) and the Medical Group Management Association (MGMA) say physician offices need to upgrade their practice management systems to 5010-compliant versions (see box).

Microwize works closely with, and recommends the following clearinghouses:

Clearinghouse Name Product ANSI 5010 Update
Relay Health Medisoft/Lytec/Practice Partner Click here
Capario Medisoft/Lytec Click here
Gateway EDI Medisoft/Lytec Click here
Navicure Medisoft/Lytec Click here
MD On-line Medisoft/Lytec Click here
Payerpath Allscripts MyWay  

 

Gateway EDI 5010 Payer Deployment for the week of 11/28/2011:

Payer Name Payer ID Type Claims after 2pm Edit for PO Box? Edit for Ambulance Locations? Reports Web Message to Clients
CO Medicare Part B 04102 837P 11/23/2011 Yes Yes 999, 277CA 11/21/2011
NM Medicare Part B 04202 837P 11/23/2011 Yes Yes 999, 277CA 11/21/2011
OK Medicare Part B 04302 837P 11/23/2011 Yes Yes 999, 277CA 11/21/2011
TX Medicare Part B 04402 837P 11/23/2011 Yes Yes 999, 277CA 11/21/2011
FL Medicaid 77127 837P 11/28/2011 Yes Yes 997, 277 11/21/2011
America's PPO 16120 837P 11/28/2011 Yes Yes 999, 277 11/21/2011
Behavioral Health Providers 19993 837P 11/28/2011 Yes Yes 999, 277 11/21/2011
Health Partners MN M3411 837P 11/28/2011 Yes Yes 999, 277 11/21/2011
Health Partners MN UB HPMNU 837I 11/28/2011 Yes Yes 999, 277 11/21/2011
Metropolitan Health Plan 10850 837P 11/28/2011 Yes Yes 999, 277 11/21/2011
Metropolitan Health Plan UB A0850 837I 11/28/2011 Yes Yes 999, 277 11/21/2011
SelectCare 10014 837P 11/28/2011 Yes Yes 999, 277 11/21/2011
UCare MN 19991 837P 11/28/2011 Yes Yes 999, 277 11/21/2011
UCare MN UB S9991 837I 11/28/2011 Yes Yes 999, 277 11/21/2011
AL BCBS 00580 837P 11/29/2011 Yes Yes 999, 277 11/21/2011
CT Medicare Part B 13102 837P 11/29/2011 Yes Yes 999, 277CA 11/21/2011
IN Medicare Part B 00710 837P 11/29/2011 Yes Yes 999, 277CA 11/21/2011
NY Medicare- Downstate Part B 13202 837P 11/29/2011 Yes Yes 999, 277CA 11/21/2011
NY Medicare- Upstate Part B 13282 837P 11/29/2011 Yes Yes 999, 277CA 11/21/2011
NY Medicare- Queens County Part B 13292 837P 11/29/2011 Yes Yes 999, 277CA 11/21/2011
DMERC Region A- CEDI 16003 837P 11/29/2011 Yes Yes 999, 277CA 11/21/2011
DMERC Region B- CEDI 17003 837P 11/29/2011 Yes Yes 999, 277CA 11/21/2011
DMERC Region C- CEDI 18003 837P 11/29/2011 Yes Yes 999, 277CA 11/21/2011
DMERC Region D- CEDI 19003 837P 11/29/2011 Yes Yes 999, 277CA 11/21/2011
American Medical Life Insurance 23212 837P 11/30/2011 TBD TBD 999 11/21/2011
Amerihealth Administrators 54763 837P 11/30/2011 TBD TBD 999 11/21/2011
Berkshire Health Partners 23243 837P 11/30/2011 TBD TBD 999 11/21/2011
D H Evans Associates 25172 837P 11/30/2011 TBD TBD 999 11/21/2011
Erin Group Administrators 23250 837P 11/30/2011 TBD TBD 999 11/21/2011
Gettysburg Health Administrators 23274 837P 11/30/2011 TBD TBD 999 11/21/2011
Lancaster General Health Network 16109 837P 11/30/2011 TBD TBD 999 11/21/2011
PA Preferred Health Network (PPHN) 06161 837P 11/30/2011 TBD TBD 999 11/21/2011
Preferred Health Care (Lancaster, PA) PHCPA 837P 11/30/2011 TBD TBD 999 11/21/2011
Preferred Health Care Systems 04320 837P 11/30/2011 TBD TBD 999 11/21/2011
South Central Preferred 23266 837P 11/30/2011 TBD TBD 999 11/21/2011
Spectrum Administrators 23253 837P 11/30/2011 TBD TBD 999 11/21/2011
The Loomis Company 23223 837P 11/30/2011 TBD TBD 999 11/21/2011
DE Medicare Part B 12102 837P 12/1/2011 Yes Yes 999, 277CA 11/21/2011
DC Medicare Part B 12202 837P 12/1/2011 Yes Yes 999, 277CA 11/21/2011
MD Medicare Part B 12302 837P 12/1/2011 Yes Yes 999, 277CA 11/21/2011
NJ Medicare Part B 12402 837P 12/1/2011 Yes Yes 999, 277CA 11/21/2011
PA Medicare Part B 12502 837P 12/1/2011 Yes Yes 999, 277CA 11/21/2011
Intercommunity Health Net INCHN 837P 12/1/2011 Yes Yes 997 11/21/2011
Samaritan Advantage SAMAD 837P 12/1/2011 Yes Yes 997 11/21/2011
Samaritan Choice Plans SAMCP 837P 12/1/2011 Yes Yes 997 11/21/2011
Samaritan Healthy KidsConnect SAMHK 837P 12/1/2011 Yes Yes 997 11/21/2011
Samaritan Health Services SAMHS 837P 12/1/2011 Yes Yes 997 11/21/2011
Samaritan Select SAMSE 837P 12/1/2011 Yes Yes 997 11/21/2011

Looking for more information? We can help. Contact our consultants. Call 800-955-0321 or click here.