5010 in 2012: Not The End of The World

Blair ElledgeQuadax, Inc.

5010 Discussion TopicsIntended Purpose, Benefits, Why Change?

5010 Transactions…much more than claims

Everyday Impact of 5010

Final Thoughts

Only 52 days to 5010!

Intended Purpose of 5010Provide the infrastructure on ICD-10

Diagnosis Codes and Present on Admission Indicators

Reduce redundancy and provide uniformity in transaction structure and usage of data content

Reduce dependency on trading partner companion guides which many entities were forced to rely on with 4010A1

Benefits of 5010Supports standardization of

Companion Guides across the industry

Supports increased use of EDI between covered entities

Supports future e-health initiatives

Why Change to 5010?Some of the changes requested include:

Better POA reporting on claims

Improved use of NPI numbers

More functional eligibility transaction that will provide greater detailed information needed by healthcare providers when making treatment decisions.   

5010 Overview

5010 TransactionsHealthcare Claims - 837 – Institutional

and ProfessionalRemittance Advice – 835Eligibility Inquiry/Response – 270/271Claim Status Inquiry/Response – 276/277Claims Acknowledgement– 277CA

5010 Transactions

Source: Palmetto GBA Website

 ANSI Transaction Description Base Version Errata Version

 270/271 Health Care Eligibility

Benefit Inquiry and Response

 005010X279  005010X279A1

 837P Health Care Claim:

Professional 005010X222  005010X222A1

 837I Health Care Claim:

Institutional 005010X223  005010X223A2

 999 Implementation

Acknowledgment For Health Care Insurance

 005010X231  005010X231A1

 835 Health Care Claim

Payment/Advice 005010X221  005010X221A1

 276/277 Status Inquiry and

Response 005010X212   N/A

 277CA Claim

Acknowledgement 005010X214   N/A

Don’t Forget Ancillary SystemsDocument imagingContract ManagementAudit Control SystemsEtc.

Everyday Impact of 5010

835 Remittance Advice

The instructions have been improved to provide a better understanding of balancing, tracking, adjustments, recovery, and other actions within the transaction.

A new data field was added for the payer to report the web address of the health care medical policies used to determine the patient’s benefits.

835 Remittance AdviceAre you posting cash?Need to test remittance advice with your

clearinhouse

Additional Information

Quadax Portal

Print File w/

Extended Data

ANSI 4010

ANSI 5010

Xpeditor Databas

e

Quadax Back-End Process

ANSI 5010Payer

Print File

If a payer is still unable to accept claims in the ANSI 5010 format after the transition date of January 1, 2012, (e.g. Workers Comp), Quadax will continue transmit claims in the ANSI 4010 format to ensure claim acceptance and payment.

Thank you!

ICD -

10