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: