San Francisco Marin Medical Society Blog

January Deadline Approaching for 5010 Transactions

SFMS is advising physicians to not expect a delay in the 5010 compliance deadline, which is January 1, 2012. All physicians, other health care professionals, payors and clearinghouses that submit HIPAA transactions will be required to use only the 5010 transactions as of the deadline. If physicians are not ready, they risk claim rejections and interrupted cash flow. Use of the 5010 code set applies to electronically submitted administrative transactions, such as checking a patient’s eligibility, filing a claim or receiving a remittance advice.

HOW to prepare for 5010

The biggest concern for practices will be complete implementation and full functionality of 5010 transactions on or before the compliance deadline to avoid transaction rejections and subsequent payment delays. If you have not yet started your conversion process, take action now. The following tips may help you meet the deadline:
  • Talk to your current practice management system vendor.
  • Talk to your clearinghouses or billing service (if you use either one) and health insurance payors.
  • Identify changes to data reporting requirements.
  • Identify potential changes to existing practice work flow and business processes.
  • Identify staff training needs.
  • Test with your trading partners, e.g., payors and clearinghouses.
  • Budget for implementation costs, including expenses for system changes, resource materials, consultants and training.

What if I’m not ready by the compliance deadline?

Any 4010/4010A1 transactions sent on or after January 1, 2012, will be rejected as non-compliant and will not be processed. CMA has queried the largest payors and published the actions they will take. If you will not be ready by the compliance deadline, talk to your trading partners, e.g., payors, clearinghouses and billing services, to determine what actions you can take to continue having your transactions processed and receive payments. Click here for more information. The Office of E-Health Standards and Services will accept complaints associated with compliance with Version 5010, NCPDP D.0 and NCPDP 3.0 transaction standards beginning January 1, 2012. HIPAA-covered entities that are subject to these complaints must produce evidence of either compliance or an established plan to become compliant within the enforcement discretion period. Complaints may be submitted electronically or via paper.

Would Payors Continue to Accept 4010?

CMA surveyed the major payors in California to find out which of them will continue to accept 4010 transactions beyond January 1, 2012. Click here for the results of which payors will continue to accept 4010 beyond January 1, 2012.

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