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Because HIPAA 5010 affects electronic transactions such as patient eligibility, claim filing, claim status, and remittance advice, payers must act now to achieve full functionality of 5010 transactions before the deadline. Otherwise, they may face transaction rejections and subsequent payment delays. Because payers are on the front line of the processes, they need to make sure that the new software is installed before the deadline, with enough time for testing with trading partners and staff training.
Business Issues
Payers face many challenges with the new 5010 transaction standards:
- Trading partners—claims clearinghouses, direct providers, employers, etc.—will all need to be compliant, depending on contracts, system upgrades may be included in current maintenance
- Payers utilizing “direct connect” EDI, meaning that providers submit claims directly to the payer, will need to upgrade their front-end validation and translation systems to accommodate the new standard
- Managed Medicare and Medicaid, as well as Medicare Advantage payers will need to upgrade their claims adjudication and EDI systems in order to send compliant transactions to Medicare and Medicaid
- Companion guides will be closely monitored by CMS
- Coordination of Benefits (COB) claims must be accepted electronically
- Complete eligibility responses will be required instead of a simple yes or no
- Remittance advice will require implementation of a web page with Health Care Medical Policy explanations
- Claims EDI adjudication system may need to be revamped
- New fields for ICD—10 code set on forms may need to be added
- Business intelligence in data may need to be applied in order to add/remove 5010 transaction changes
Critical questions every executive should be asking:
- How do I perform an inventory of existing systems to determine which will be affected by the change?
- What are my vendors’ upgrade plans?
- Will my business partners and clearinghouses be ready by the deadline?
- What mapping changes are required for implementation?
- Will my billing service or clearinghouse increase their fees for the 5010 transactions?
- When can I send test transactions to them to make sure the system will work?
- How can I plan ahead for changes in work flow and staff training to minimize disruption?
- What is the cost of training resources?
- How do I know which transactions to test and will we conduct the testing with test data or live production data?
Why should you consider Ingenix as a 5010 partner?
Our comprehensive solutions can help your organization use the 5010 transition as a springboard to improved operating effectiveness:
- Consulting Services—Wide-ranging expertise to help organizations assess, plan, and implement HIPAA 5010, ICD-10, and other solutions
- Ingenix Claredi®Classic—HIPAA 5010 and 4010A1 preproduction transaction testing and certification
- Ingenix Faciledi®—In-stream validation and routing of HIPAA x12 5010 and 4010A1 transactions
- Connectivity Director—Direct B2B EDI exchange with providers and secure trading partner management system
- Transaction Exchange—National health care clearinghouse for providers and payers
- Payment Solutions—Integrated EFT/ERA for electronic payment to providers
- Ingenix Learning and Development Services—Online or onsite classes to educate functional and technical staff on HIPAA 5010
GET STARTED NOW.
Contact Ingenix to discuss your 5010 preparation.
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