ANSI 5010
Deidre Lawson Fryfogle- Product Manager
What is ANSI 5010?
• ANSI 5010 is a new electronic format that is
being mandated by the federal government
for all electronic claims submissions.
Benefits of ANSI 5010
• Provides infrastructure on ICD-10 and Present
on Admission Indicator
• New Standard ANSI Responses
– ANSI 277CA (Level 2 response)
– ANSI 999 (Acknowledgement)
Transactions Converting to ANSI 5010
• ANSI 837 – Professional, Institutional, and
Dental claims
• ANSI 835 – Electronic Remittance Advice
• ANSI 270/271 – Eligibility Verification
• ANSI 276/277 - Real Time Claim Status
ANSI 5010 Changes
• Billing Provider Loop (2010AA)
– Cannot send P.O. Box in N3 Address segment.
– 9 digit zip code is required for the billing provider.
ANSI 5010 Changes Cont.
• Facility Loop (2310C)
– 9 digit zip code required in Facility Address
• Added REFs to support provider Legacy PIN number (moved
from 2010AA)
• Loops and Segments have been removed or changed.
– Responsible Party and Purchased Service providers are
deleted
– DME information moved to FRM segments
ANSI 5010 Changes Cont.
• Additional Segments added to better report
specialized information
• Ambulance pickup and drop off locations
added
• COB requirements have been modified
• Allow up to 10 Other Insurance Payers to be
reported
ANSI 5010 Conversion
• We have provided multiple utilities to help make your provider records
5010 compliant.
• The new Fields button allows the vendor to have access to all of our fields,
both 4010 and 5010, as well as access to our data mapping.
Provider Address Update
• A new vendor utility will allow you to update
the billing and pay-to addresses for all
provider records for a customer.
• Search Tools  Report Manager Provider
Address Update
Provider 5010 Readiness
• Practice Insight has partnered with USPS to do a one
time sweep to validate the provider address and update
with the 9 digit zip code.
• The Provider 5010 Readiness report will allow you to
identify the providers that are still not 5010 compliant.
• Missing a 9 digit zip
• P.O. Box in the billing
• Search Tools  Report Manager Provider 5010 Readiness
Post Conversion Routine
• For those new 5010 claim-level errors that
may be difficult for your PM to account for,
Practice Insight has created a Post Conversion
Routine, which will allow us to automatically
substitute customer specific claim data upon
claim conversion from 4010 to 5010.
– Available upon request
EDIFECS Engine for 5010 Claims
• What is EDIFECS? According to their website: “Edifecs
XEngine is an enterprise-strength, high-throughput
message processing engine that provides deep (SNIP
Levels 1-7) and accurate validation of transactions at
the edge-of-the-enterprise.
By catching errors early, XEngine separates good data
from bad data thus allowing organizations to comply
with legislative and company mandates.”
EDIFECS Engine for 5010 Claims Cont.
• In other words, EDIFECS provides an extra level of
validation and testing for our ANSI 5010 claims.
• As an extra measure to make sure that all of our
5010 claims are compliant, all 5010 claims process
through the EDIFECS validator before being sent to
the payer.
• A new status response with a source of EDIFECS will
be returned on all claims found in error. The claim
status will be INVALID.
Additional Program Modifications
• All of the 5010 screens for Professional and
Institutional claims have changed to
accommodate the change in data for these
formats.
5010 Industry Timelines
• Mandatory compliance on January 1, 2012
for all covered entities
• Small health plans have until January 1,
2013
• ICD.10 compliance is October 1, 2013
Practice Insight Timelines
• Participating in the National Testing Week with CMS the
week of August 22 – 26, 2011.
• Scheduled to begin transitioning payers to 5010 format this
September.
• http://www.practiceinsight.net/pi-website/page52.htm
• Weekly emails will be sent with notifications of payer
transitions.
• All payers to be switched to ANSI 5010 by December 31,
2011.
What You Can Do To Prepare
• Educate yourself on the format change. Purchase the
new ANSI guides(WPC-edi.com)
• Start using 9 digit zip codes!!!
‣ Facility records in Practice Management
‣ Provider records in PM and PI
• Identify your customers with PO Box addresses in the
Billing Provider loop move this to the Pay-To Provider
loop
• TEST! If you would like to test your claims, please contact
PI and we can give you instructions on how to test.
What to Watch Out For
• With all ANSI transaction formats
changing:
–Watch claims
–Watch responses
–Monitor Payments
–Stay ALERT!!
Be a Hero!!
Be proactive! Your providers are counting on you!
Resources
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WPC Website (ANSI guides):
www.wpc-edi.com
CMS Website:
http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp
EDIFECS Website:
http://www.edifecs.com/products/core_products/xengine/
ICD10 Website:
http://www.icd10watch.com/blog/7-benefits-hipaa-5010
Questions?