ANSI Version 5010: Are you ready to generate new standard transaction formats?      
Beginning January 1, 2012, the new HIPAA electronic transaction standard, ANSI Version 5010 (v5010), will be the only transaction version that will be accepted by BCBSNM and other payers. All covered entities* will be impacted, including hospitals and physician practices. Assessing your readiness and the readiness of all of your vendors is critical. This includes successful completion of the testing of ANSI v5010 transactions prior to the January 1, 2012, implementation date.

If your practice management system and billing entities (billing service and/or clearinghouse) are unable to support ANSI v5010 transactions on January 1, 2012, BCBSNM will be unable to process your electronic claims (ANSI 837 transactions). In addition, other HIPAA-standard Electronic Data Interchange (EDI) transactions, such as eligibility and benefits inquiries (ANSI 270/271), claim status requests (ANSI 276/277), and the Electronic Remittance Advice (ANSI 835 ERA), must also conform with the new ANSI v5010 standard transaction format.

Note: Practice management/hospital information system software developers and vendors are not required to be HIPAA-compliant. It is your responsibility to contact your software vendor to confirm that your system is running the most current HIPAA-compliant software.

Who is your primary contact?
Many providers use a billing service and/or clearinghouse to handle their health care transactions, such as claims. Who has been assigned the task of getting your claims “out the door” to BCBSNM? Are all of your claims sent electronically? Does your vendor ever “drop” your claims to paper for submission to BCBSNM?

If your billing service is your primary contact, and if you have not done so already, you should ask what it has done to meet the mandated requirements of ANSI v5010 and what it needs from you to help ensure you will be in compliance.

By knowing your primary contact and becoming aware of the additional contacts and the exact route your transactions take from your office to your payers, you will be better equipped to resolve any problems.

Know where your claims go
Many providers believe their claims are submitted directly to BCBSNM, but almost all claims go through intermediaries before arriving at BCBSNM. An intermediary could include a practice management system (PMS) or hospital information system (HIS), a billing service, or one or multiple clearinghouses.
       
Since a claim may be handled by multiple entities along its way to us, there is a potential for processing delays at each of these points. At each point of contact, the transaction must be validated before it can move on to the next point of contact. A transaction can progress to the next entity only if it meets all requirements—including all new claim submission mandates, such as those related to use of the National Provider Identifier (NPI) and changes to Billing Provider Address/Loop 2010AA requirements.

If it meets all of the format and data requirements along the way, the transaction is forwarded to our primary claims clearinghouse where it is subjected again to format and data validation. If the transaction passes this point of review, it goes to BCBSNM. Failure to pass the validation requirements will result in rejection, sending the transaction back to the point of origin.

After a claim leaves your office, it should not become “out of sight, out of mind.” Follow up with your primary contact. The contact should be confirming whether transactions were received and were passed successfully on to the next entity. Ask your primary contact these questions:

• Did your primary contact receive a successful report?
• If the claim was rejected at the next connection point, ask why or ask for your response reports.
  
• Were any rejections/errors fixed so the transaction could continue?
  
• Is each intermediary entity along the way preparing for the conversion to ANSI v5010? Is each entity testing now? When will each entity be fully compliant?
  

Get involved in your own claims process. ANSI v5010 is coming and you need to test now to continue receiving claims payments. Make your primary contact accountable. Make sure you and your staff are trained and ready.

Paper claims are not the solution
Though providers submitting paper claims are not immediately impacted by the conversion from ANSI v4010 to v5010, now is a good time to convert to a practice management system that supports electronic medical records as well as electronic claim filing. This allows providers to take advantage of government incentives, which could in turn help cover the related costs. It will also likely ease the conversion to ICD-10, which all covered entities must complete by October 1, 2013.

For more information
Visit the ANSI v5010/ICD-10 page of our website, where you can:

• View preparation tips and timeline reminders
• Find links to helpful resources on other sites, such as the Centers for Medicare & Medicaid Services (CMS)
  
• View answers to frequently asked questions
  
• View webinar dates and times and register online
  

Need assistance? E-mail your ANSI v5010/ICD-10 questions to us.

*Covered entities include health plans, clearinghouses, health information trading partners, health information networks, and health care providers who transmit HIPAA transactions electronically.

The above information is for educational purposes and is not legal advice. If you have any questions about compliance with the various laws or regulations, you should consult with your legal advisor.
 

Blue Review • October 2011 • bcbsnm.com