5010 Enforcement Delay Set

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  • December 2, 2011
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The Centers for Medicare & Medicaid Services (CMS) Office of E-health Standards and Services (OESS) recently announced that it’s loosening its ASC X12 Version 5010 standards compliance enforcement with a 90-day discretion period for all Health Insurance Portability and Accountability Act (HIPAA) covered entities. It has come just in time before the compliance Jan. 1, 2012 deadline; however, is it enough time to meet compliance expectations?
CMS said it will initiate enforcement on office-based physicians, health insurance plans, and claims clearinghouses starting March 31, 2012. CMS made this decision based on industry feedback from organizations and their trading partners who aren’t ready to finalize system upgrades to 5010 standards. Providers must comply, regardless.

That doesn’t mean, however, that providers have a delay of implementation. While the payers may not be implementing 5010 January and there will be no penalty, failure to use 5010 means no reimbursement still.
Medical Group Management Association (MGMA) asked CMS to “immediately issue a comprehensive contingency plan,” allowing health plans to continue processing non-compliant health care claims. MGMA was prompted to do this after a members’ survey indicated only 35 percent had begun internal testing for 5010 use. The survey also indicated that one in five practices (approximately 22 percent) “had not even scheduled internal testing with practice management system vendors,” according to ModernHealthcare.com.
Robert Tennant, MGMA’s Washington-based senior policy adviser, said it was “good they didn’t wait” until the end of December to make the announcement, but it still doesn’t solve all of the problems dead ahead. He also said, “We continue to be concerned about the ability of health plans to accept a 5010 claim that might not have all of the content, but enough content to adjudicate a claim.”
“CMS has to look seriously about allowing 4010 claims for a considerable length of time,” Tennant said. “We strongly encourage the government to monitor the industry. If things don’t improve, they’ll have to look seriously about augmenting this decision they made today.”
Take Advantage of the Extra Time
Now is the time to make sure you are ready for the March 31 compliance deadline. CMS advises in a press release:
“OESS encourages all covered entities to continue 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. While enforcement action will not be taken, OESS will continue to accept complaints associated with compliance with Version 5010, NCPDP D.0 and NCPDP 3.0 transaction standards during the 90-day period beginning January 1, 2012. If requested by OESS, covered entities that are the subject of complaints (known as “filed-against entities”) must produce evidence of either compliance or a good faith effort to become compliant with the new HIPAA standards during the 90-day period.”
Visit the ICD-10 website for resources to help you prepare and to download the implementation widget.
5010 Crisis May Loom Despite Grace Period,” ModernHealthcare.com, Nov. 18, 2011
CMS Nov. 17 Press Release

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No Responses to “5010 Enforcement Delay Set”

  1. Jenn says:

    Good morning,
    When you state “That doesn’t mean, however, that providers have a delay of implementation. While the payers may not be implementing 5010 January and there will be no penalty, failure to use 5010 means no reimbursement still.”, can you please provide the source for this information? I cannot find anything stating CMS has provided direction that they will not reimburse Fee For Service claims because they were submitted on the 4010 or any other earlier version of the 837 yet. In fact, in a conference call on Wednesday, December 7th, they indicated that this direction to the MACs is still pending. We are trying to provide clear direction to our Senior Management and gather facts so any links or information you can share on this would be very much appreciated. Thank you!!