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• InstaMed 5010 and ICD-10 Bulletin

Delivering a Smooth Transition to 5010

As a single, integrated healthcare and payments platform, InstaMed will support you during the transition from ASC X12 Version 4010 to ASC X12 Version 5010.  Our objective is to minimize the impact during this transition period. You can continue to send your current formats.  InstaMed will track which format is required by each payer and convert accordingly. However, we recommend that you monitor our service alerts so you are aware of our payer transition schedule.

Top 5010 Issues

Claims

For address requirements, check these configurations in your practice management system or make the updates in the Configure > Healthcare area of InstaMed Online.

• Zip codes for the Billing Provider (2010AA) and Service Facility (2310C) addresses must be valid 9-digit codes.
• If you receive payments at a P.O. Box address, ensure that your Billing Provider (2010AA) address is a physical location and that the P.O. Box is set as the Pay-To Provider (2010AB) address.
• The Rendering Provider (2310B), Service Facility (2310C)  or Pay-To Provider (2010AB) information cannot be the same as the Billing Provider (2010AA) information. If they are the same as the Billing Provider, do not include them.
• Non-specific procedure codes require additional description for some payers. Non-specific codes may include Not Otherwise Classified (NOC), Unlisted, Unspecified, Unclassified, Other, Miscellaneous or Prescription Drug codes. In 5010 claims, the description should be sent in the Service Line (SV101-7 for professional  claims or SV202-7 for institutional claims). In 4010 claims, the description may be sent in a Line Note indicating Additional Information (NTE*ADD). The description must start with DESC= in order for it to be converted correctly into the 5010 format by InstaMed.
• Professional claims that include drug codes (NDC) must include the drug quantity and composite unit of measure (for example, 10 ML) in the 5010 format. This information is sent in the Drug Quantity (CTP) segment of the Drug Identification (2410) loop for a given service line. This information can be sent the same way in 4010 claims; it is only the usage that has changed to be required in 5010.
• The provider’s Contract Information (CN1) should not be sent.
• For payers that issue unique identification numbers to each member, the Subscriber (2000B) information should be sent only and should not be repeated as the Patient (2000C) information. This scenario applies to all Medicaid and some commercial payers. The Subscriber is also commonly called the insured or guarantor.

Eligibility

• InstaMed is updating how Workflow Status is applied to eligibility transactions in InstaMed Online. The update applies primarily to the scenario in which the patient is covered by a Medicare replacement plan, otherwise known as Medicare Part C or a Medicare HMO. Prior to the 5010 transition, successful inquiries for patients with a Medicare replacement plan would be assigned a workflow status of Needs Review. CMS introduced changes to the content of eligibility responses with 5010, which resulted in these inquiries being assigned a Workflow Status of Active Coverage with Restrictions. In order to accommodate this change, the update will impact other scenarios where information about another payer is returned. Primarily, these scenarios will include inquiries to Medicaid and commercial payers where the patient is Medicare-eligible. These inquiries previously were assigned the Active Coverage with Restrictions Workflow Status and now will be assigned Needs Review. The update will restore the expected behavior for CMS inquiries and ensure that the Needs Review Workflow Status is assigned in this scenario. It also will make the assignment of workflow statuses more consistent and appropriate across our supported payers. These changes will go into effect on April 1, 2012.
• CMS is returning “Required Data Application Missing” when trailing spaces are found in alphanumeric fields such as names, identifiers and addresses. Remove trailing spaces from your provider configurations and patient information and resubmit. Click here for more information.
• Aetna is returning the “Invalid Provider Identification” error when the NPI is not sent or not registered with the payer. Ensure you’re sending your NPI or go to www.AetnaNPI.com for instructions on registering your NPI. An exemption form is available for providers who are not NPI-eligible.

5010 Transition Schedule

InstaMed is continuing to switch payers to the 5010 format. Claims and eligibility transactions will be sent in 5010 format to select payers. The lists below show payers that are not accepting 5010 yet. You can continue to send your current formats, and InstaMed will provide conversion services.

Payer Lists

Professional Claims

Eligibility

Monitor and Report

Monitor your claims and eligibility transactions for the payers listed above, and report any issues to InstaMed Customer Service.

When You Should Convert to 5010

CMS has announced another extension of the enforcement discretion period for 5010 compliance through June 30, 2012. However, the large majority of payers are ready to accept transactions in the 5010 format now. You may switch the format sent from your practice management system at any time, but please review the payer lists to confirm whether your key payers are 5010 ready.

What’s Next?

InstaMed will continue to make updates to our payer lists in the coming weeks. Please continue to review the lists and look out for additional announcements.