Posts Tagged ‘5010’

Patient Eligibility Checks – The Proactive Provider Is Doing Them

In Uncategorized on August 22, 2013 at 8:44 pm

Pursuant to 5010 requirements (the regulatory requirements attendant to the electronic submission and processing of your claims), as of January 1, 2013 all payers were supposed to have been officially obligated to offer “real time eligibility.”  What this means to your practice is that if you were to submit a patient eligibility information request to a payer to confirm that that patient is in fact covered for his/her upcoming appointment, then that payer has 20 seconds in which to respond to that request.  Twenty seconds – that is the new standard, as of January 1, 2013. 

As anyone who has performed an eligibility check well knows, the eligibility information received from the carrier varies by carrier.  Some provide only a yes or no response to the question of eligibility; others may provider the co-pay amount, the amount remaining on co-pay, eligibility for ancillary services (optical, dental, mental health, DME, etc…).  And because of this diversity of response, the helpfulness of the information varies as well.  In the coming years, this data is anticipated to be legislatively standardized as well, so that all carriers are providing the same information to eligibility inquiries.

Now, while the regulation currently places this imposition on the carriers, and there is no penalty to providers for NOT seeking eligibility information, the practical implication to the practice is that the standard/duty of care regarding eligibility may gradually shift from the patient to the provider….  What once used to be the onus of the patient (to ensure eligibility, or be responsible for payment in full if not eligible), may become that of the provider…  food for thought.

As always, please feel free to contact M.E.D.I.C., Inc. if you have any questions regarding eligibility issues.


Slight 5010-Compliance Reprieve

In Uncategorized on November 17, 2011 at 6:16 pm

CMS has announced that it will NOT enforce 5010 non-compliance until March 31, 2012.  This is a slight reprieve, but all HIPAA covered entities should be actively in testing mode, and continually “working with their trading partners to become compliant with the new HIPAA standards, and to determine their readiness to accept the new standards as of January 1, 2012.”

For the full text of the CMS statement, please see:

CMS Sets National 5010 Testing Day For June 15, 2011

In Uncategorized on May 12, 2011 at 6:56 pm

Beginning on January 1, 2012, a federal mandate requires health plans, clearinghouses, and providers to use new standards in electronically conducting certain health care administrative transactions at the heart of daily operations, including claims, remittance, eligibility, and claims status requests and responses.
Upgrading from the current HIPAA 4010A1 transaction standards to the new 5010 standards addresses several key goals:

  • Increase transaction uniformity
  • Support pay for performance
  • Streamline reimbursement transactions

As the deadline approaches, affected health care organizations need to upgrade and test their claims management systems to accommodate 5010 and prevent operational disruptions.

Two key factors prompted the upgrade to 5010: 1) the government and industry’s shared goal of providing higher quality, lower cost health care, and 2) the need for a comprehensive electronic data exchange environment for the vastly expanded ICD-10-CM and PCS code set transition mandated for compliance by October 1, 2013.

To this end, the Centers for Medicare and Medicaid Services is encouraging all Medicare trading partners to participate in National 5010 Testing Day on June 15 as part of preparations to comply with the HIPAA 5010 transaction sets by January 2012.

Local Medicare Administrative Contractors will be disseminating information on transactions being tested on June 15 and some Medicaid programs also will participate, with details to come.