5010 Quick Tips

As the deadline for 5010 compliance rapidly approaches, there are critical changes providers must make to ensure claims are processed successfully to payers who will accept only 5010-compliant claims.

Update your address book to keep payments flowing: When submitting 5010-compliant transactions, the billing provider and service facility addresses must be complete, physical street addresses and can no longer be a PO Box or lock box.

To direct remittances (payments) to a different address, use the pay-to-provider, name and address fields.

Depending on the health plan, you will receive warning messages or rejection errors for incomplete street address fields.
Put 9 on the line: With 5010-compliant transactions, the billing provider and service facility addresses must be complete street addresses and can no longer be a PO Box or lock box.

Complete is defined as including the full 9-digit ZIP code: traditional 5-digits plus the extra 4 digits for localized mail delivery.

Depending on the health plan, you will receive warning messages or rejection errors for incomplete street address fields.

The Centers for Medicare and Medicaid Services (CMS) will be validating the ZIP+4 sent in for both billing provider and service facility. Please ensure you are properly registered in the PECOS system for Medicare before changing this data in your PM system.

Check out the ZIP code directory look-up, and plan to update your address fields and PM system accordingly.

* Prior to making changes in the practice management system, providers should validate their credentialing and/or enrollment with health plans to ensure payments will not be negatively affected.
Minutes matter: For professional claim transactions, the reporting of anesthesia minutes was revised. In 4010, payers could require the anesthesia time be reported as the total number of minutes or as units. In 5010, you can only report the total number of minutes. Units are no longer an acceptable format for reporting anesthesia time. Any requirements by a payer to submit anesthesia start and stop times in the 5010 transaction will be noncompliant with the TR3.
Billing provider clarification: In 5010, a billing provider must be a provider of health care services and can no longer be a billing service or clearinghouse. New clarifications to the definition of a billing provider include:

Billing providers must now be those entities that perform services that are reimbursed by health plans.

Make sure you are using the correct NPI for your organization. This must be the same NPI identifier for all trading partners.

The Tax ID must be sent for the Billing Provider on the claim.
Patients are a virtue: As your payers become capable of sending and receiving 5010-formatted transactions, please remember that, for health plans that assign a unique identifier per member, the individual must be listed as a subscriber. The patient is not listed on the transaction.

For health plans that assign a number to the entire family, follow these rules:

The policy holder is always listed as the subscriber.

If the policy holder is the patient, the patient is not listed in the transaction.

If the dependent is the patient, they are listed as the patient in the transaction.

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	Update your address book to keep payments flowing When submitting 5010-compliant transactions, the billing provider and service facility addresses must be complete, physical street addresses and can no longer be a PO Box or lock box. To direct remittances (payments) to a different address, use the pay-to-provider, name and address fields. Depending on the health plan, you will receive warning messages or rejection errors for incomplete street address fields.
	Put 9 on the line With 5010-compliant transactions, the billing provider and service facility addresses must be complete street addresses and can no longer be a PO Box or lock box. Complete is defined as including the full 9-digit ZIP code: traditional 5-digits plus the extra 4 digits for localized mail delivery. Depending on the health plan, you will receive warning messages or rejection errors for incomplete street address fields. The Centers for Medicare and Medicaid Services (CMS) will be validating the ZIP+4 sent in for both billing provider and service facility. Please ensure you are properly registered in the PECOS system for Medicare before changing this data in your PM system. Check out the ZIP code directory look-up, and plan to update your address fields and PM system accordingly. * Prior to making changes in the practice management system, providers should validate their credentialing and/or enrollment with health plans to ensure payments will not be negatively affected.
	Minutes matter For professional claim transactions, the reporting of anesthesia minutes was revised. In 4010, payers could require the anesthesia time be reported as the total number of minutes or as units. In 5010, you can only report the total number of minutes. Units are no longer an acceptable format for reporting anesthesia time. Any requirements by a payer to submit anesthesia start and stop times in the 5010 transaction will be noncompliant with the TR3.
	Billing provider clarification In 5010, a billing provider must be a provider of health care services and can no longer be a billing service or clearinghouse. New clarifications to the definition of a billing provider include: Billing providers must now be those entities that perform services that are reimbursed by health plans. Make sure you are using the correct NPI for your organization. This must be the same NPI identifier for all trading partners. The Tax ID must be sent for the Billing Provider on the claim.
	Patients are a virtue As your payers become capable of sending and receiving 5010-formatted transactions, please remember that, for health plans that assign a unique identifier per member, the individual must be listed as a subscriber. The patient is not listed on the transaction. For health plans that assign a number to the entire family, follow these rules: The policy holder is always listed as the subscriber. If the policy holder is the patient, the patient is not listed in the transaction. If the dependent is the patient, they are listed as the patient in the transaction.