Case Study

Apex EDI Started the journey to being 5010 Compliant years ago. We learned a lot along the way and want to share the lessons we learned form being 5010 compliant every step of the way.

WHAT IS 5010?

5010 is the most current version of the HIPAA electronic transaction standards.

If you submit electronic healthcare transactions, such as filing a claim, checking a patient’s eligibility, or receiving remittance advice you should be aware of the 5010 HIPAA electronic transaction standards. 5010 is the nickname for the Version 005010 specification created by the Accredited Standards Committee (ASC) and approved by the Department of Health and Human Services for Implementation.

WHY DID WE HAVE 5010?

Essentially, 5010 upgraded the way insurance payers can receive information and better exchange information about the patients you see. The upgrade also allows for the larger field size of coming ICD-10 codes as well as other improvements.

WHY WAS THE 5010 TRANSITION DIFFICULT?

Practices reported numerous problems as a result of the transition to Version 5010. The most frequently reported problems have involved:

1. Issues with practice management and/or billing systems that showed no problems during the testing phase with their MAC, but once the practice moved into production phase, found their claims being rejected
2. Issues with secondary payers
3. Rejections due to various address issues (pay-to address being stripped/lost from claims; pay to address can no longer be the same as billing address; no PO Box address)
4. Crosswalk NPI numbers not being recognized
5. “Lost” claims with MACs
6. Old submitter validation information not being transferred
7. Certain “not otherwise specified” claims being denied due to not having a description on the claim (CMS sent a notice of correction of this issue Jan. 27, 2012)
8. Sporadic payment of re-submitted claims (with no explanation for rejections)
9. Protracted call hold times (most typically 1-2 hours) when attempting to contact MACs for further explanation of unpaid and rejected claims (a problem that dates as far back as November 2011)
10. Unsuccessful claims processing (with no reason cited for rejection) despite using a “submitter” that was approved after successful testing with CMS

Some insurance companies were unable to complete the 5010 readiness requirements and are still operating under the old 4010 standards.

Many of these problems resulted from entities across the industry inability to coordinate testing efforts and an unfortunate switchover during a long holiday. The lack of foresight to see that these conditions would result in a breakdown of the healthcare billing system was unprecedented.

WHAT APEX EDI DID RIGHT?

At Apex EDI our foremost goal is to get providers paid fast and easy. Furthermore, we want to be available quickly to help resolve any problems you face. Our goal with the 5010 transition was to make the transition completely transparent to you despite the massive changes required. However, even with all of our preparations, the transition did not meet our standard for being completely transparent. We aggressively worked to provide you the high level of service we aim to provide.

What we did to provide this service?

1. We added additional phone capacity
2. We“loosened” data validations in order to allow more claims to move through the system
3. We augmented our website hardware to make the system more responsive
4. We had our programmers working around the clock to speed our system
5. We increased our customer support staff to improve phone responsiveness
6. We continued to make adjustments to our system to accommodate payer and provider needs

If you continue to have questions or concerns about 5010, schedule a demo.