Intended Purpose of 5010 Provide 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 5010 Supports 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 Transactions Healthcare Claims - 837 – Institutional and Professional Remittance Advice – 835 Eligibility Inquiry/Response – 270/271 Claim Status Inquiry/Response – 276/277 Claims Acknowledgement– 277CA
5010 Transactions Source: Palmetto GBA Website ANSI TransactionDescriptionBase VersionErrata 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 Systems Document imaging Contract Management Audit Control Systems Etc.
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 Advice Are you posting cash? Need to test remittance advice with your clearinhouse
Print File w/ Extended Data ANSI 4010 ANSI 5010 Xpeditor Database Quadax Back-End Process ANSI 5010 Payer 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.