5010 Compliance
5010 Updates and Announcements
We are pleased to report that in 2011 Pulse successfully completed developing the enhancements to enable your medical organization to process claims in compliance with the new mandatory 5010 standards. In addition, we successfully completed our testing with all major clearinghouses and those direct connect payers that are ready.
While our efforts represent a significant accomplishment there is more work to be done. Most of our Pulse users have made a smooth transition to filing claims under the 5010 rules. However, these mandated rules have caused significant system changes with all stakeholders’ Health Information Systems including payers and clearinghouses, causing issues with claim rejections, reports and payments delays. Many payers were not ready in advance of the deadline and work remains.
As a result, we are currently experiencing a heavier than normal call volume on the Pulse Help Desk, causing longer than expected wait time and response delays to our clients. Our Help Desk is also being challenged by significant delays in getting answers from the various clearinghouses. Payer and clearinghouse responsiveness is now extended to several days.
We are sensitive to the fact that claims issues impact your bottom line and we have implemented additional support as follows:
- Providing additional staff to address the number of support issues and questions that are coming in as a result of the transition;
- Implementing additional claim scrubbing rules due to more restrictive edits for claim file acceptance to resolve editing issues and reduce the need for additional proofing;
- Delivering software maintenance and updates that are specific to claim issues.
We will send out broadcast emails to make clients aware of any scheduled software maintenance that is claim related and any additional information regarding the 5010 transition. In addition, we encourage you to thoroughly review the following:
- Release notes that were previously published on PACE during the 4thquarter 2011, the release notes should inform you of setup or workflow changes that may be necessary to comply with the required changes. Examples:
- The billing provider address may not contain a P.O. Box or a lockbox address
- The billing provider zip code must be nine digits (Company table)
- The service facility zip code must be nine digits (Facility table)
- If an NDC is required for the procedure code on the claim, the Units and Unit of Measure must be included.
- When an NDC code is sent on a claim, you must use one of the following approved measurements: International Unit (F2), Gram (GR), Milligram (ME), Milliliter (ML), Unit (UN).
- Unspecified procedure codes may require additional documentation in the Notes. If you have questions about this requirement, contact the specific payer.
- Monitor your claims for rejections, and incoming payments as you always do, until you are satisfied that all information is transmitting properly. If you encounter any issues or need further assistance, please contact the Pulse Support Team.
- Continue to look for new information regularly posted on PACE;
- Pulse EDI (previously known as Pulse Gateway) information bar to review clearinghouse and payer alerts.
- Broadcast emails from Pulse announcing claim related software maintenance and other information.
Other helpful reference documents to become familiar with the new standards:
MGMA-letter-to-HHS-regarding-payment-disruptions-caused-by-HIPAA-Version-5010.pdf
Professional Claim 837-P 4010A1 to 5010 Side by Side [PDF, 442KB]
Institutional Claim 837-I 4010A1 to 5010 Side by Side [PDF, 372KB]
Remittance 835 4010A1 to 5010 Side by Side [PDF, 91KB]
Claim Status 276/277 4010A1 to 5010 Side by Side [PDF, 179KB]
Eligibility 270/271 4010A1 to 5010 Side by Side [PDF, 313KB]
NCPDP 5.1 to D.0 Side by Side [PDF, 28KB]
Excel formats – Professional, Institutional, NCPDP claims [ZIP, 351KB]
Excel formats – Remittance, Claim Status Inquiry and Response, Eligibility Inquiry and Response [ZIP, 310KB]
