Frequently Asked Questions

To reiterate, RelayHealth’s up-convert and down-convert services will NOT cover everything a Provider needs to do to prepare for 5010.  To avoid increased claim rejections, a decrease in worker’s productivity, and a negative impact on cash flow, we are providing some additional recommendations to better prepare for the transition.

Below is a list of key areas of change within 5010 standards, with the highest impact to Providers, which would cause Payer rejections if not addressed. While this is not meant to be a comprehensive list, Providers need to review and prepare their software or systems now to ensure the necessary changes are made to meet the following new requirements before the industry deadline of 12/31/2011. By incorporating these changes, Providers will significantly increase the likelihood of meeting the Payers’ requirements for 5010.  More detail on all the 5010 requirements can be found on Collaboration Compass.

 

Top 5 most common 5010 Payer rejections RelayHealth has identified include: 

1. Billing Provider Address

  • The Billing Provider Address is required to be a physical Street Address.
  • PO Box or Lock Box addresses are to be sent in the Pay-To Address when necessary.
  • RelayHealth will reject claims that contain either a PO Box or Lock Box.
  • 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.
  • Professional and Institutional Loop 2010AA/Data Element N301 and N302.

2. 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 use a default of ‘0000’ for the missing last four digits. If a Payer does not accept a default, RelayHealth will reject the claim.
  • This applies only to Provider submitted legacy formatted data that is up-converted to a Payer’s 5010 standards.
  • Claims will reject that do not contain a 9-digit zip code for Payers that are 5010 Live when you send a 5010 inbound format to RelayHealth.
  • Professional Loops 2010AA, 2310C and 2420C/Data Element N403.
  • Institutional Loops 2010AA and 2310E/Data Element N403.

3. Provider Accept Assignment Code

  • Changed from a situational to a required data element.
  • When a value is not sent, RelayHealth will default a value of ‘A’ (Assigned).
  • This applies only to Provider submitted legacy formatted data that is up-converted to a Payer’s 5010 standards.
  • Claims will reject that do not contain a valid value for Payers that are 5010 Live when you send a 5010 inbound format to RelayHealth.
  • Professional and Institutional Loop 2300/Data Element CLM07.

4. Priority (Type) of Admission or Visit

  • Required for all Institutional claims.
  • When a value is not sent, RelayHealth will default a value of ‘9’ (Information Not Available).
  • This applies only to Provider submitted legacy formatted data that is up-converted to a Payer’s 5010 standards.
  • Claims will reject that do not contain a valid value for Payers that are 5010 Live when you send a 5010 inbound format to RelayHealth.
  • Institutional Loop 2300/Data Element CL101.

5. Drug Quantity

  • The CTP segment has changed from ‘situational’ to ‘required’ when Loop 2410 is present.
  • RelayHealth will reject claims that do not contain the CTP segment when Loop 2410 is present.
  • Professional and Institutional Loop 2410/Segment CTP.

The changes required for 5010 standards are the foundation for supporting future ICD-10 code sets.  All systems must be upgraded to new 5010 standards in advance of implementing ICD-10 diagnosis code standards that go into effect October 1, 2013.

Eligibility

270/271

Enrollment

834

Claims

837 P/I

Remits

835

Claims Status

276/277

Referrals/ Authorization

278

Mandates additional service types such as chiropractic, emergency services, pharmacy, vision and professional visits

Improves privacy protections

Separates diagnosis code reporting

Clarifies rules for use

Allows prescription number reporting

Provides specific information on conditions

Clarifies dependent and subscriber relationships

Adds additional information, such as enrollment subtotals and coverage reasons

Clarifies use of NPI

Eliminates “not advised” elements

Eliminates sensitive information to satisfy privacy concerns

Asks for number of occurrences

Requires alternate search support

 

Provides greater consistency between dental and professional claims

Clarifies and strengthens rules for balancing

Instructions for batch and real time use

Separates segments for key patient conditions

 

 

Simplifies COB requirements

Can be used with 4010 claims

 

Supports and expands authorization exchanges

 

 

Enables use of POA indicator

Includes new medical policy segment

 

 

The new HIPAA 5010 standards will yield greater accuracy and efficiency of EDI transactions, eligibility, billing, claims processing, reimbursement, many administrative functions and accommodate the larger set of ICD-10 codes. 

RelayHealth is supporting these 5010 standard transactions: 

  • 270 Eligibility Inquiry
  • 271 Eligibility Response
  • 834 Enrollment
  • 837 Professional & Institutional Claims
  • 835 Remittance Advice
  • 276 Claim Status Inquiry
  • 277 Claim Status Response
  • 278 Referrals/Authorization

RelayHealth understands the conversion to the 5010 standard is a mission critical industry initiative. Our focus is to make the process as simple and seamless as possible for our customers. That is why RelayHealth offers two services to help Providers with this important initiative.

Down-Convert Service: In the event that a Payer is not ready to support the new 5010 standard, RelayHealth can receive the Provider’s 5010 file and “down-convert” it to the Payer’s 4010 standard. The Provider will still receive the Payer-specific edits that they depend on RelayHealth to perform. This service can be used until the Payer accepts the 5010 format.

Up-Convert Service: If a Payer begins requiring only 5010 files before the Provider is able to send the 5010 standard, RelayHealth can work with the Provider to ensure the Provider delivers adequate data within the 4010 file (or current format) to satisfy the 5010 requirements. In this case, RelayHealth can receive the Provider’s 4010 file (or current format) and “up-convert” it to the 5010 standard. However, Providers must provide the required data to be used by RelayHealth to create the 5010 transaction to the Payer. This data may also be required to ensure efficient processing of the claim by the Payer when submitted via printed claim.

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