Medisoft ANSI & Lytec ANSI 5010- Frequently Asked Questions
Government mandated changes on all Electronic Claims Submission could jeopardize your practice if you don’t make the necessary changes. If you are not sending your electronic claims according to the HIPAA requirements of ANSI 5010 your claims will be rejected. It is crucial that you understand these drastic changes and are ready for them so you don’t experience huge disruptions in your cash flow.
What is ANSI 5010? Can it really be that important?
ANSI 5010 is the new version of HIPAA transaction standards that regulates the electronic transmission of healthcare transactions. The 5010 standards will replace the existing 4010 / 4010A1 version. 5010 changes will support the forthcoming ICD-10 coding.
If getting paid is important to you- then Yes; Preparing for ANSI 5010 is not only important, but critical, essential, A MUST (is that clear enough?)
How do I prepare for ANSI 5010?
Upgrade to Medisoft Version 17 or Lytec 2011 both are ANSI 5010 ready and will protect your cash flow.The software contains all the data fields necessary to generate ANSI 5010 enabled claims. And to make things easier on you the software also includes drop-down menus and the English equivalent of codes to help guide billers. As a result, billers don’t have to be expert coders (or memorize a bunch of new codes) in order to submit claims with the correct information the first time.
Set up your software to Send 5010 Claims
Change Office Workflow such as Demographic entry and Charge entry
Work closely with your clearinghouse and/or payers to ensure you are meeting the new requirements. Every clearinghouse and payer is handling this change differently so they are by far the best source to contact to understand why rejections are happening and how to fix them. Obviously this change is drastically affecting everyone so expect higher wait times when calling them.
When must the transition to ANSI 5010 be complete?
ANSI 5010 standards went into effect January 1, 2012 with a grace period until March 31, 2012. Payers decide when they will begin accepting only 5010 claims within that time frame. Contact your clearinghouse/payers to understand which claims you should be submitting.
What if my clearing house says they will make the necessary changes so I don’t have to upgrade my software?
Currently most rejections reported are from those using older versions of software that are not 5010 compliant where the clearinghouse is attempting to “up-convert” the data. This practice is risky and is not recommended.
Following is a list of 5010 changes that are most likely to result in rejected claims if not handled properly. We encourage you to have a conversation with your clearinghouse to determine how it will address these changes if your software is not ANSI 5010 compliant.
- 9-Digit ZIP Code: The 5010 standards require a 9-digit ZIP code for the billing provider and service facility location. If a 9-digit ZIP code is not sent when 5010 goes into effect, your clearinghouse may add a default for the missing last four digits. If a payer does not accept a default, they may reject the claim.
- Billing Provider Address: The billing provider address must be a physical street address. As payers transition to using the 5010 standards it is expected they will begin requiring an address for billing providers and reject a PO Box or lock box. Payers may enforce this change at any time as they prepare for and complete the transition to 5010.
- Provider Accept Assignment Code: This data element was changed from a situational to a required data element with 5010. Claims may be rejected if they do not contain a valid value for payers that are live on 5010.
- Release of Information Code: Several Release of Information Code values in HIPAA 4010 are no longer valid in 5010. As payers move to version 5010, providers may experience claim rejections when the Release of Information Code contains a value of A, M, N, or O. The 5010-allowed values are “I” (Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes) and “Y” (Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim).
- Subscriber/Patient Hierarchical Level Changes: If a patient can be uniquely identified to the destination payer in Loop 2010BB by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop 2000C is not used. Providers should review registration processes to ensure this information is captured appropriately. Medicare and Medicaid recipients are identified uniquely. Blues and commercial plans vary. Member ID cards should be reviewed for unique member assigned identifiers.
- Remaining Patient Liability: This is a new segment and is the remaining amount to be paid after the adjudication by the Other Payer identified in Loop 2330B/2400. This data is required to balance the claim.
What are some of the fields that changed or were added to meet the new requirements?
- Practice Email
Patient / Guarantor Information
- Race- Based on the US Census Guidelines
-American Indian or Alaskan Native (I)
-Pacific Islander (P)
- Ethnicity- Based on US Census Guidelines
- Death Date
Case Policy 1 Tab
- Group Name
Case Policy 2 Tab
- Medicare Secondary Reason (only if Insurance 2 is Medicare)
-Black Lung (41)
-Disabled Beneficiary Under Age 65 with LGHP (43)
-End-Stage Renal Disease (13)
-No-fault Insurance including Auto is Primary (14)
-Other Liability Insurance is Primary (47)
-Public Health Service (PHS) or Other Federal Agency (16)
-Veteran’s Administration (42)
-Worker’s Compensation (15)
-Working Aged (12)
Case Conditional Tab
- Nature of Accident
-Injured at home
-Injured at school
-Injured during recreation
-Work Injury / Self Employed
-Work Injury / Non-Collision
-Work Injury / Collision