GE Healthcare
5010:
Cynthia Klain
April 2011
Agenda
• Who are we?
• 5010 Background
• Payer Readiness and Testing
• Areas of Impact
• Processing Strategy
• Questions?
GE Centricity® EDI Services
A full service EDI solution dedicated to improving your
revenue cycle through service and automation.
Delivering Value With Integrated Transactions:
Eligibility - 270/271
Claims Status – 276/277
Referrals - 278
Electronic Claims - 837
Electronic Remit - 835
GE Centricity® EDI Services
Healthcare Transactions per month:
1800+ Customers
4 GE Centricity PMs (Practice, Group, Business, Enterprise)
~16 million Claims/month
~$6 Billion in gross charges!!/month
~15 Million Remits/month
~5.5 Million Eligibility/month
5010 BACKGROUND
5010/ICD-10 Timeline
ICD-10
5010
Compliance Date
January 1, 2011
Enforcement Date
January 1, 2012
Implementation Date
October 1, 2013
‘11
‘12
‘13
‘09
June 18,
2010:
Centricity
EDI
Services is
ready for
5010
April 1,
2011; payers
should be
ready to test
with “errata”.
Only ~30%
are ready
Claims with
Date of
Services on
October 1,
2013 or after
will utilize
ICD-10!
Transactions that are Changing
with X12-4010A1  X12 5010
• 270/271 Eligibility Inquiry &
Response
• 837 Professional and
Institutional Claim
• 835 Remittance Advice
• 276/277 Claim Status
Request & Response
• 837 Dental claims
• 278 Referral/ Authorization
Request & Response
5010 Overview
Mandate Overview
The X12 5010 transactions replace the 4010 HIPAA transactions and are needed to
accommodate ICD-10 codes and address other identified issues with 4010
Changes
Impact
New Data Elements/Records
and Updated Segments
New Storage locations/Processing/Screens
Translations Scripts/Tools/PM
Update Data requirements
Updated Edits/rejections
Updated Adjudication Systems
New Edits/Billing processes
Who’s affected?
Customers
Centricity EDI
Trading Partners
Payers
PAYER READINESS AND
TESTING
Update on Payer Readiness
Target Date
May 2010
Activity
Centricity EDI began Trading Partner Readiness Calls
-Repeated calls every 30 days to 90 days
Summer
2010
August –
December
2010
April 2011
Q3 2011
Continued Payer Calls, but received very little information. One
payer indicated readiness soon; Highmark (PA BCBS)
•Began testing with Highmark (PA BCBS)
-Tested various billing specialties & input formats (4010 & 5010).
-Mid-Oct = Highmark Production!
•All payers contacted for 5010 readiness
•30 of 143 payers indicate readiness to test, but all require testing in
April with the “Errata” Version
•Currently TESTING with our top 30 claim payers
•Currently PRODUCTION with Kansas Medicaid, Highmark BCBS
and Emdeon. Production approved with several others (GA
Medicaid, most Noridian payers)
•Testing with CMS/Medicare Eligibility in the next few weeks
Most payers available for testing
Trading Partner Readiness Outreach
•When can we begin testing 5010 with you?
(for each transaction 837P, 837I, 835,
270&271)
•Is 5010 testing required?
•When (what date) is 5010 transaction
mandated? (for each transaction type 837P,
837I, 270)
•If we send a 5010 claim file (837) will we be
able to get the 5010 remit back (835)?
•When will the 5010 remit (835) be available?
•Will 5010 testing be only for compliance or
will it also test payer specific edits?
•Will we be getting reports back after testing
5010?
•Will you be ready to test and go live on 5010
across all transactions at the same time?
(837, 835, 270&271) If not at the same time,
what is the schedule?
•Are you planning to allow dual submissions
of 4010 and 5010 at the same time or will it
be a hard cutover only to 5010 claim
submissions?
•Will there be any transmission/connection
changes to how we technically send you are
claims?
•Will there be any enrollment or re-enrollment
required before submitting 5010?
•Will we be able to test the 270 and get 271
transaction back?
•How will you be communicating when you
cutover or mandate the 5010 transaction?
(website, letter, email, etc.)
•Will you be changing the length of any of the
fields in the 835 (ERA) (policy #, check #,
ICN)
•When we go live with 5010 will you be
replacing the 997 report with the 999 report?
Will there be any other changes to reports or
new reports?
•Are you mandating with implementation of
5010 that the Billing Provider
Address(2010AA N3) no longer be a PO Box
and that it MUST be a street address? Will
the providers need to complete re-enrollment
if they are currently sending the PO Box and
need to start sending the street address?
Top 30 Payer Testing Status
Won't return calls, 1
Approved, 2
Production, 2
Waiting on Test
Login info, 3
Major Delays; > 2
months, 9
Testing in progress, 6
Minor Delays (1-2
months), 7
•16 of the 30 have major or minor delays. We’re tracking when we can
move to PRODUCTION, since test and production are often not the
same.
•We are testing both 5010 and upconverted 4010. LIVE with some
upconverts!
•Team meets weekly to track status, identify new payers to test, discuss
issues. 143 unique connections.
AREAS OF IMPACT
High to Medium Impact
Issue
What is this?
Work Around
What to do NOW!
PO Box in the
Billing Provider
and Service
Location Loops
PO BOX address are no
longer allowed in these
fields. A physical street
address must be sent.
Send the physical
address! We’ve also
had some success
with POBOX and
P0B0X.
Know what you are
submitting! Look for
WARNINGS and
ALERTS as we do
more end to end
testing.
Zip+4 is
The 5010 specification
required in the
requires the zip+4 in some
Pay-To-Provider loops
Loop
Send the zip+4!
We’ve also has some
success with a
default value of 9998
Know what you are
submitting! Look for
WARNINGS and
ALERTS as we do
more end to end
testing.
Subscriber
Definition
changes
TBD – Dependent on
payer interpretation
Know what you are
submitting
If the dependent has a
unique member ID, then
this is submitted in the
subscriber loop (the
patient loop is not used
Medium to Low Impact
Issue
What is this?
Work Around
What to do NOW!
Place of Service =
HOME
If the Place of Service
is HOME, this must be
the physical street
address of the patient.
Send the physical
address! We’ve also
had some success
with POBOX and
P0B0X.
Front desk protocol
check – are you
capturing the street
address? Look for
WARNINGS.
Anesthesia Claims
Should be reported
only as minutes
Submit correctly
Know what you are
submitting.
Ambulance Billing
Now requires physical
pick-up/drop off
address
Submit correctly. TBD
on how payers will do
this (ex: mile marker
25?)
Know what you are
submitting.
Worker’s Comp
Claims
Several new fields
required
Submit correctly.
Know what you are
submitting
PROCESSING STRATEGY
Electronic Claims Strategy
Assumptions/Clarifications
Payer Ready
to Test
Centricity EDI Alerts internal teams. Begins
5010 “certification process” with various
input and claims types for a sub-set of
customers
As payer mandate date
approaches, Centricity EDI
begins sending X12 5010 for all
customers
Validation
Receipt of file (reports)
Payment
Process is Complete
- Centricity EDI Can translate X12 4010 TO X12 5010
most of the time
-Centricity EDI Can translate X12 5010 TO X12 4010
all the time
-After your CPS upgrade, Centricity EDI does not
need to make customer set up changes to accept
updated versions of Inputs.
-Centricity EDI will begin sending X12 5010
transactions to payers as payers are ready and/or
mandate it
Electronic Remit Strategy
New Mandate
Identified
1st 5010 ERA
file is
received
Centricity EDI alerts internal
teams
Is Customer able to process x12
5010 (835)?
N
Y
Centricity EDI Translates
Incoming file to X12 4010
Centricity EDI begins
sending customer X12
5010 files
Customer is upgraded
Process is Complete
Eligibility Strategy
Payer Ready
to Test
Centricity EDI Alerts internal teams. Begins
5010 “certification process” with various
input and claims types for a sub-set of
customers
As payer mandate date
approaches, Centricity EDI
begins sending X12 5010 for all
customers
Validation
Receipt of 271
Process is Complete
-Assumptions/Clarifications
- Centricity EDI Can translate X12 4010 TO X12 5010
most of the time for BOTH 270 and 271
-Centricity EDI Can translate X12 5010 TO X12 4010
all the time
-After your CPS upgrade, Centricity EDI does not
need to make customer set up changes to accept
updated versions of Inputs.
-Centricity EDI will begin sending X12 5010
transactions to payers as payers are ready and/or
mandate it
Summary
• Get ready for CPS v10!
• Impacted Areas: Know what
your sending!
• Look for WARNINGS and
ALERTS (Centricity EDI
Users).
• Look for additional monthly
updates and webinars.
• Prepare for a few hiccups.
Payers are delayed in testing.
Useful Resources
5010 Resources
ICD-10 Resources
• Government Bills –
legislation
• General Information
www.gpoaccess.gov/bills/index.html
• HHS Web Site –
regulatory
www.aspe.hhs.gov/admnsimp/index.s
html
• Workgroup for Electronic
Data Interchange (WEDI)
www.WEDI.org
• Washington Publishing
www.wpc-edi.com/registry
• ANSI X12
www.x12.org
http://www.ahima.org/icd10/
Questions?