ANSI 5010 Professional Claims
5010 Readiness Update RelayExchange™ Transaction Services – Claims, Remits, Claim Status
RelayHealth Completes 5010 Errata Updates
October 19, 2011 September 1, 2011
RelayHealth has completed implementation of the 5010 Errata changes for all supported
claims-
The 5010 Errata changes were finalized by the X12 committee last year and published as additions to the final documentation. Errata impacted the industry by requiring all entities to make adjustments to systems and RelayHealth has completed the necessary changes. The 5010 Errata changes primarily address workers compensation and property casualty claims, as well as some field movement, including changes to some situational and required fields.
Throughout 2011, we will continue testing 5010 with Errata standards with external payers and partners as they complete their testing and readiness plans. During this time, we strongly encourage you to first submit test files to RelayHealth and analyze test results from RelayHealth prior to moving to 5010 production transactions.
Readiness Steps for Providers
RelayHealth is ready to work with you as your organization becomes 5010-
Step 1: Complete Your Practice Management Readiness
To begin 5010 testing with RelayHealth, your practice management system must be able to produce content to support 5010 claims transactions. Work with your practice management system vendor (or your IT department if you have a proprietary system) to ensure you are on track to produce your claims transactions in the 5010 format.
Step 2: Continued Payer Edit Testing
RelayHealth will be updating the system throughout 2011 with 5010-
Please contact your RelayHealth Support Team or Account Executive if you need further assistance planning for your 5010 transition.
RelayExchange™ Transaction Services 5010 Format Changes
Affect Professional Providers
Transition to the ANSI X12 5010 format for professional claims will require data changes which may impact your business processes and claim process procedures. This document highlights key areas of change within 5010 standards with the highest impact to our customers. Please review and prepare your software or systems to ensure the necessary changes are made to meet the following new requirements before the industry deadline of 12/31/2011.
Billing Provider Address
The Billing Provider Address must be a Street Address.
PO Box or Lock Box addresses are to be sent in the Pay-
This change may potentially affect contractual reimbursement if used as a data element by a payer to crosswalk NPI and subsequently may require coordination with the payer.
9 Digit Zip Code
5010 standards require a 9 digit zip code.
RelayHealth will reject claims if the full 9 digit Zip Code is not present.
Providers may begin submitting full 9 digit Zip Codes prior to their 5010 conversion.
Subscriber/Patient Hierarchical Level Changes
If a patient can be uniquely identified to the destination payer in Loop 2010BB by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop 2000C is not used.
Providers should review registration processes to ensure this information is captured appropriately. Medicare and Medicaid recipients are identified uniquely.
Blues and Commercial plans vary. Member ID cards should be reviewed for unique member assigned identifier.
COB Balancing (Click on COB Balancing link for an explanation of COB)
Remaining Patient Liability is a new segment and is the remaining amount to be paid after the adjudication by the Other Payer identified in Loop 2330B/2400. COB data is required to balance the claim.
There are additional technical changes described in the attached document, which should be shared with your IT staff to ensure your RelayHealth interface is updated accordingly. This information should be shared with additional staff as appropriate.
RelayHealth will continue to help you navigate through this key industry initiative. Please visit Collaboration Compass often for additional 5010 information.
ANSI 837 V5010 to CMS-
For a complete cross reference of CMS 1500 form to ANSI 5010 Loop and Segment click
on the ANSI 837 V5010 to CMS-
Common 5010 Rejections and Requirements
RelayExchange™ Transaction Services
RelayHealth has been actively testing 5010 claim transactions with Medicare, Medicaid, BlueCross BlueShield, and commercial payer lines of business. Through our extensive testing we have identified that each payer line of business is continuing to reject test claims from providers because they do not meet 5010 Errata requirements. You are responsible for making updates to your current production environment to ensure your smooth transition to 5010 production standards.
Rejection: Missing or invalid other payer ID.
Cause: Payer ID information must be complete for Primary, Secondary and Tertiary insurance carriers in both primary and secondary fields.
Corrective Action: Edit the carrier, go to the EDI Tab and enter the Payer ID for the carrier in both the primary and secondary fields. Do this even if the carrier is set to print to paper instead of electronic submission. If the carrier does not accept electronic claims and has no Payer ID, use a generic number like OT123 or 9999.
National Provider Identifier (NPI)
- The NPI of the organization health care provider or its subpart is reported as the Billing Provider in Data Element NM109 of Loop 2010AA.*
- If the organization health care provider has enumerated subparts, then it is required that the subpart’s NPI be reported as the Billing Provider.
- The subpart reported as the Billing Provider must always represent the most detailed level of enumeration.
- Must use the same organizational health care provider’s or subpart’s NPI for all the payers to whom you submit claims.
- Review subpart enumeration schemas
- If re-
enumerating, communicate those changes to your business partners (payers, clearinghouses, trading partners, etc). - May require enrollment or system updates for your business partners in order for them to identify new or changed numbers for your organization.
- Contact your business partners’ Enrollment Department for instructions on updating your NPI in their systems.
- Update the National Plan and Provider Enumeration System (NPPES).
- Service Facility NPI
- NPI is not allowed within the Service Location for health care providers except when the Service Location is not part of the Billing Providers’ organization.
- Must be an external entity to the Billing Provider identified in Loop 2010AA,* for example, an Independent Reference Laboratory.
- Subparts with unique NPIs from the Billing Provider may no longer be sent in the Service Location and must be sent as the Billing
- Individual NPI
- Required for individual providers when the role of the provider is influenced by the Billing Provider: Attending, Rendering, Supervising, Operating, Other Operating.
- Required only when known for: Referring, Purchased Service and Ordering.
- Loops Multiple,* Data Element NM109
- COB Balancing (Click on COB Balancing link for an explanation of COB)
- COB data is required to balance the claim after adjudication by the Other Payer identified in Loop 2330B/2400.*
- Remaining Patient Liability is a new AMT segment and is the remaining amount to be paid after adjudication by the Other Payer.
- COB Payer Paid Amount is reported in an additional AMT segment.
- Claim or Line Level Adjustments must be reported in the CAS segment to report prior payers’ claim level adjustments.
- Amounts and Adjustments must balance to the charge amount at both the claim and service line levels.
- Loops 2320 and 2430,* Segments AMT and CAS.
- Admission Date
- Required for all claims with inpatient medical visits and for all ambulance claims when the patient was known to be admitted to the hospital.
- Must be on or before the Discharge Date.
- Required when Type of Bill (TOB) is Inpatient.
- Must not submit Admission Date on claims for which it is not required.
- Loop 2300,* Data Element DTP03.
- Health Care Diagnosis Code
- Must be sent with value of ‘BK’ ICD-
9- CM until ICD- 10- CM takes affect 10/01/2013. - RelayHealth will reject claims that do not contain a value of ‘BK’.
- Loop 2300,* Data Element HI01-
1.
- Drug Quantity
- The CTP segment has changed from situational to required when Loop 2410, LIN03 National Drug Code (NDC) is present.
- RelayHealth will reject claims that do not contain the Drug Quantity when NDC is present.
- Loop 2410,* Data Element CTP04.
- With 5010 NDC numbers are required on ALL injections. NDC numbers must be 11 characters
long. A leading zero must be added if the NDC number is 9 or 10 digits in the segment.
It must be in a 5-
4- 2 format.
- Patient Reason for Visit
- Required when the claim involves outpatient visits.
- Must bill the correct Patient Reason for Visit Code based on the Revenue Code and Type of Bill combination.
- Loop 2300,* Segment HI.
- Provider for the claim.
- Loop 2310E,* Data Element NM109
- 9 Digit Zip on Select Fields
- 5010 standards require a 9 digit zip code for both the Billing Provider and Service Facility Location.
- Providers may begin submitting full 9 digit Zip Codes prior to their 5010 conversion.
- If a 9 digit zip code is not sent, RelayHealth will edit in “0000” for the missing last four digits. However, if a payer does not accept that, RelayHealth will reject the claim.
- NOTE: Medicare will not allow “0000” for the last four digits.
- Please work with your payers now to update crosswalks with your 9 digit zip code.
- Loops 2010AA and 2310E,* Data Element N403
- Billing Provider Address
- The Billing Provider Address is required to be a physical address.
- PO Box or Lock Box addresses are to be sent in the Pay-
To Address when necessary.
- RelayHealth will reject claims that contain PO Box or Lock Box anywhere in the Address.
For example: PO Box, Box, P.O. , P.O. Box, P.O.Box, P O Box, POBox
- This change may potentially affect contractual reimbursement if used as a data element by a payer to crosswalk NPI and subsequently may require coordination with the payer. Please work with your payers now to update crosswalks with a street address.
- PO Boxes must be separately sent in the Pay-
to fields. - Loop 2010AA, Data Elements N301 and N302
- Special Characters
- Do not use #, :, , -
in any fields. The most common character is the # sign. Instead of using this for suite numbers or apartment numbers, spell out numbers or use “apt.” or ste.
You are encourage you to start sending 5010 production claims to the 5010 live payers, as listed in the Payer Transition Schedule on Collaboration Compass.