5010 is an electronic data interchange version of the ANSI X12 formats for all HIPAA financial and administrative transactions for claims, remittance advice, eligibility, and claim status query and response transaction, plan enrollment, and referral authorization transactions. 5010 is for all covered entities (health care provider that conducts certain electronic transactions, clearinghouse or health plan). 5010 is not just for Medicare.
It is important to identify the differences between the current 4010A1 formats and the 5010 formats. You, your vendor and/or clearinghouse should perform a 4010A1 to 5010 gap analysis. You should identify: new content, deleted content, modified content and impact to business needs. Communicate and coordinate with your staff as well as your vendor, clearinghouse and payers to insure all impacts are identified early. Know your vendor's schedule. Know your trading partner's schedule. Test both internally and externally.
5010 Affects the following Business Processes:
- Claims (837 Institutional, Professional, and Dental)
- Claim Status (276/277)
- Claim Payment (835)
- Enrollment (834)
- Premium Payment (820)
- Eligibility (270/271)
- Referrals and Prior Authorizations (278)
- Claims Acknowledgements (277CA)
- Acknowledgement for Health Care Insurance (999)
Medicare Schedule: Medicare contractors will begin testing with submitters as early as January 2011. The 5010 formats must be used as of January 2012. It is important that you begin your 5010 preparations and discuss your readiness with your vendor and/or clearinghouse. Medicare will conduct the 837, 276/277, 277CA and 999 transactions in the 5010 format.
Medicare does not anticipate any extension on the 2012 compliance date. January 2012 is quickly approaching. You should start now to ensure a successful implementation. If you fail to prepare, it will be your business and cash flow that will be affected.