HBMA Develops Standard Definitions for 5010 Readiness

The Healthcare Billing & Management Association (HBMA), a nonprofit educational resource and advocacy group representing third-party medical billers and billing professionals, has developed standard definitions for 5010 readiness for providers, software vendors, clearinghouses, and health plans in response to the inconsistency of definitions found between each entity. The association shared these definitions with Centers for Medicare & Medicaid Services (CMS) officials in a letter, dated October 10, 2011.
 
For nearly a decade, medical providers have been required to submit electronic medical claims using a federally approved Transaction Code Set (TCS). The original TCS–4010 is scheduled for a federally mandated upgrade and replacement to TCS–5010 on January 1, 2012. For months, providers, health plans, and others involved in the electronic claims submission industry have announced that they were ready to begin testing and/or processing transactions via the new 5010 standard. However, once moving into the testing phase, it became apparent to HBMA’s members that providers and health plans had different definitions of what it meant to be ready to submit and process 5010-compliant claims.
 
“Successful testing between providers and health plans is essential to a smooth transition from 4010 to 5010 and to ensure that claims are submitted and paid via electronic transactions. If providers and health plans are suddenly unable to ‘talk’ to one another via the new standards, the providers’ claims will not be properly processed or paid by the health plans—creating serious cash flow and operational problems for physicians and other healthcare professionals,” says Holly Louie RN, CHBME, PCS, cochair of the HBMA ICD-10 Committee, which developed the standards.   
According to the letter, “HBMA recommends the definition of ‘ready’ specifically include compliance with each published standard by the regulatory implementation date. Further, HBMA strongly recommends that payors must be restricted to limited, standardized, and approved companion guides, and only when absolutely necessary.”
 
Under HBMA’s proposed standards, providers and clearinghouses are “5010 ready” when they have successfully completed a production submission of claims (837) and received the associated remittance (835) for those claims in compliance with the 5010 specifications. Specific tactics include the following:

• completion of all practice management system upgrades;
• confirmation of successful testing with direct submission carriers;
• confirmation of successful testing with clearinghouses where applicable;
• confirmation of successful production submission of claims (837); and
• confirmation of successful retrieval of the claims’ associated remittance (835).
  

By the same definitions, payors and clearinghouses are considered “5010 ready” when they have successfully accepted a production submission of claims (837) and returned the associated remittance (835) for those claims in compliance with the 5010 specifications. Specific tactics include the following:

• completion of all system upgrades;
• confirmation of successful testing with direct submitting providers;
• confirmation of successful testing with clearinghouses where applicable;
• confirmation of successful acceptance of production claims (837) submission; and
• confirmation of successful return of the claims’ associated remittance (835).  
  

“In presenting this standard definition of 5010 readiness to CMS, our goal is to provide a definition that will be accepted across the industry as a uniform standard,” adds Louie. “If all participants engaged in the transition from 4010 to 5010 agree on the meaning of ‘ready,’ the term will have more credibility and value for those communicating with each other. We hope our proposal will be favorably received by CMS. Given there are less than 50 business days before the implementation date of Jan. 1, 2012, we hope their swift action on this issue will help to limit industry confusion during this critical transition period.”
 
HBMA and the HBMA ICD-10 Committee remain interested and available to work with CMS and other entities on implementation of the proposed standard definitions for 5010 readiness. Additionally, organizations are encouraged to view the standards on HBMA’s website as a basis for guidance when evaluating business partners and vendors.
 
Source: Healthcare Billing & Management Association