New 5010 Standards for Electronic Health Care Transactions

What’s New in 5010?
5010 HIPAA Implementation
for
January 1, 2012

2
Agenda
I. New Federal Standards for Electronic Health Care
Transactions
II. 5010 Testing Readiness
III. MassHealth 5010 Web Site
IV. 5010 Transactions and Software Modifications
V. 837I Institutional Claims
VI. 837P Professional Claims
VII. New 999 Acknowledgement Transaction
VIII. 270/271 Eligibility Verification
IX. 276/277 Claim Status
X. EVSpc Highlights

New Federal Standards for Electronic
Health Care Transactions
3
 The Centers for Medicare & Medicaid Services (CMS)
have introduced new standards for electronic health care
transactions as of January 1, 2012.
 All electronic health care transactions must change from
version 4010/4010A to version 5010 on January 1, 2012.
 MassHealth will no longer process any 4010 claims after
this date.
 Providers must submit all claims in 5010 electronic
format.

5010 Testing Readiness
4
■ On November, 17, 2011 the Centers for Medicare &
Medicaid Services’ Office of E-Health Standards and
Services (OESS) Announced a 90-Day Period of
Enforcement Discretion for Compliance with New HIPAA
Transaction Standards.
■ MassHealth has relaxed testing requirements to allow
trading partners to send in a file thru December 16, 2011.
■ MassHealth will continue to work towards a January 1,
2012 implementation date in order to comply with the
federal mandate.
■ Providers can use DDE if they are not ready to test for
5010 after 1/01/12.

MassHealth 5010 Web Site
■ If you are submitting paper claims after 1/1/2012:
– Use the CMS-1500 claim form when submitting
Professional paper claims to MassHealth. Refer to
the MassHealth CMS-1500 Billing Guide for applicable
5010 instructions.
– Use the UB-04 claim form when submitting Institutional
paper claims to MassHealth. Refer to the MassHealth
UB-04 Billing Guide for applicable 5010 instructions.
■ Revised MassHealth billing and companion guides for
HIPAA – Version 5010 appear on the MassHealth 5010
website:
http://www.mass.gov/eohhs/gov/newsroom/masshealth/p
roviders/mmis-posc/hipaa-version-5010.html
5

5010 Transactions and Software Modifications
 POSC – Provider Online Service Center
 General 837 Changes
 837P – Professional Claims
 837I – Institutional Claims
 837 – COB (Coordination of Benefits)
 270/271 – Eligibility Verification
 276/277 – Claim Status
 999 – New transaction replaces 997
 EVSpc – Eligibility Verification System Software
(270/271 & 276/277)
6

5010 Transactions and Software Modifications
General 837 Claim Changes
7

837 HIPAA Electronic Claim Transaction
 A nine-digit zip code must be submitted.
 No PO Box address should be sent on a claim – street
addresses only.
 Electronic billers may place P.O. box information in the
pay-to address loop. Paper providers must provide a DBA
address.
 You can now submit up to 12 diagnosis codes per claim,
with a maximum of four per service line.
 When applicable, claims must include additional drug
information and qualifiers, such as NDC code, quantity,
composite unit of measure and prescription date and
number.
8

 Providers must report their NPI* on all claim submissions.
 New pick-up and drop-off codes must be submitted when
billing for ambulance or non-emergency transportation
services.
 F5 qualifier (Patient Paid Amount) deleted – Providers
must use the F3 qualifier (Patient Estimated Amount
Due).
 Acute inpatient hospitals must provide a POA (Present on
Admission) indicator for the Principal, Other, and External
Cause of Injury segments.
 Taxonomy code qualifier change (ZZ to PXC).
 The patient reason for visit must appear on all out-patient
claims to comply with the HIPAA Implementation Guide.
* Except providers who are exempt from the NPI requirement (i.e. Atypical Providers) 9

 When applicable, all ingredients for a compound drug
prescription must be identified on the claim, and have the
same prescription number or the same linkage number, if
provided without a prescription.
 Anesthesia services billed with procedure codes must
indicate a specific time period defined in the code
description. Otherwise, these services must be reported in
minutes.
 Anesthesia services reported in units will no longer be
accepted.
10

 All MassHealth providers must enter an ICD-9 diagnosis
code on all claim submissions. All paper claims must also
contain diagnosis information.
 If prior authorization (PA) is required* for a service on a
claim:
- Enter the PA at the header level for the entire claim.
- Enter the PA at the service line when it differs from the
one entered at the header level.
 If a referral is required* for a service on a claim:
- Enter the referral at the header level for the entire
claim.
- Enter the referral at the service line when it differs from
the one entered at the header level.
* Please note that if a PA or referral is on file in POSC, providers can also submit claims without these
numbers and the system will match the claim 11

837 Coordination of Benefits (COB)
 Payer paid amount must balance at both the service line
and the claim level. The provider billed amount on the
service line should balance to the sum of the service line
payer paid amount and service line adjustment reason
code amounts.
The “total non-covered amount” must be submitted in
lieu of providing the prior payer amount, and any
adjustment segments previously submitted in exception
billing.
Check remittance date cannot be submitted at both the
claim and service line level. For community health, you
must put the date at the service line level.
12

 Use any of the following electronic options to submit COB
claims to MassHealth:
 Batch 837P or 837I submission
 Coordination of Benefits (COB) / Direct Data Entry
(DDE) through the Provider Online Service Center
(POSC).
13

837I POSC Transactions
837I
Institutional Claims
Billing and Service Tab -
Billing Information
14

837I POSC Transaction Screen
■ “Last Name” field increased from 35 to 60
characters.
■ “First Name” field increased from 25 to 35
characters.
15
60 Characters 35 Characters

■ “Other Physician” field renamed
“Other Operating Physician”
16
“Other Operating Physician” fields

■ Patient allowed to assign/refuse benefits to
Provider.
■ “Provider Accepts Assignment” dropdown list
updated – “Not Applicable” option added.
17
New option added

■ “Medicare Assignment “field renamed “Provider
Accepts Assignment”.
■ “Provider Accepts Assignment” dropdown list
updated.
– “Patient Refuses to Assign Benefits” removed.
18

837I
Billing and Service Tab –
Service Information
19

■ “Covered Days” and “Non-Covered Days” fields
removed as indicated by arrows pointing to
previous location for each field.
20
Removed fields

■ “Patient Status” entry required
21
Select the
Patient Status
Patient Status
box

■ Admit Source – renamed to “Admission or Visit
Type” – required for all inpatient and outpatient
services.
 I – Inpatient Hospital L – Long Term Care
 O – Outpatient H – Home Health Claims
22
Former Admit Source field

■ “Admission Type” renamed to “Admission or Visit
Type”. This field requires entry.
■ “Patient Paid” field removed. Please use Value
Code FC on the Extended Services Tab.
■ On the Extended Series tab, select the Value
Code “FC – Patient Paid Amount – UB 04 Only”.
23
Former “Admission Type” field

■ “Delay Reason Code” field added with a
dropdown box. Supports electronic 90-day waiver
and Final Deadline Appeal requests*.
24
Select the
Delay Reason Code
New field added with dropdown box
* Please refer to All Provider Bulletins 220 and 221 for additional instructions

837I
Extended Services Tab
25

■ List of diagnoses increased from 28 to 41.
26

■ Principle Diagnosis must be entered for all 837I
claims.
27
Select
Code
Enter Description

■ Type field modified so you can select
“PR – Visit” up to three times. All other options
can only be selected once.
28

■ “Present on Admission” field added.
■ Dropdown list added on Diagnosis Code Detail
panel.
– Valid values are N, U, W, Y or blank.
29
New field

■ New field allows entry of the accident state.
30
New field

■ Home Health Care Information – entire panel section
containing the following removed:
– Prognosis Indicator, Certification Type, Surgical
Procedure Type, Patient Location Code, Medicare
Coverage Ind and Skilled Nursing Facility Ind.
– Most services require PA and/or documentation to be
kept by the provider. Some fields removed were
duplicative of our regulations in subchapter 4 of the
HHA manual (treatment plans, etc., that have to be
kept &/or submitted with a PA request, etc.)
31

837I
Procedure Tab
32

 Drug Identification section with five new fields.
NDC
Units – changed from 8 to 11 with three numbers after
the decimal point allowed.
Units of Measurement (F - International Unit removed.)
 Rx Qualifier
 Rx Number
33

837I
Attachments Tab
34

■ “Description” field removed from Attachments tab.
■ Report Type – List of Values has been updated.
35
Top half of
Report Type
dropdown list

■ Report Type – List of Values has been updated.
36
Bottom half of
Report Type
dropdown list

837I
Coordination of Benefits Tab
37

■ “Remittance Date” field renamed from “EOB
Date”.
■ “Remaining Patient Liability” field added.
■ Allowed Amount Field removed.
38
Former “EOB Date” field

■ Total “Non-Covered Amount” field added.
■ “Payer Paid Amt” renamed to “COB Payer Paid
Amount”.
■ User must enter an amount in either the “COB
Payer Paid Amount” field or the “Total Non-
Covered Amount” field (but not both).
39
COB added
Enter Amount at Claim (COB) or Line Level
Amount Aids in
Claim Adjudication

■ “Claim Filing Indicator” list updated.
40
Dropdown list updated

Claim Filing Indicator dropdown list updated.
 Codes Deleted:
 09 - Self-pay
 10 - Central Certification
 LI - Liability
 Codes Added:
 17 - Dental Maintenance Organization
 FI - Federal Employees Program
41

■ Subscriber Date of Birth and Gender Removed.
■ “Group Name” renamed from “Plan Name”.
42
Former “Plan Name” field

■ Inpatient Adjudication Information – Any COB
payer’s remark codes can be entered here.
43
Former “Medicare Inpatient Adjudication Information” field

■ Outpatient Adjudication Information – Any COB
payer’s remark codes can be entered here.
■ “Lifetime Reserve Days” field removed.
44
Former “Medicare Outpatient Adjudication Information” field

 Payer paid amount must balance at both the service line
and the claim level. The provider billed amount on the
service line should balance to the sum of the service line
payer paid amount and service line adjustment reason
code amounts.
 The “total non-covered amount” must be submitted in lieu
of providing the prior payer amount, and any adjustment
segments previously submitted in exception billing.
 Check remittance date cannot be submitted at both the
claim and service line level. For community health, you
must put the date at the service line level.
45

■ Maximum Number of COB reason records
increased from 10 to 30.
46
COB reason records increased

(DDE) POSC Transactions
837P
Professional Claims
Billing and Service Tab –
Billing Information
47

837P POSC Transaction Screen
■ “Last Name” field increased from 35 to 60
characters.
■ “First Name” field increased from 25 to 35
characters.
48

■ “Patient Refuses to Assigns Benefits” removed from the
“Provider Accepts Assignment” dropdown box.
■ “Not Applicable” option allows the patient to refuse to
assign benefits to the provider.
49

■ “Medicare Assignment” field renamed to
“Provider Accepts Assignment”.
50
Former Medicare Assignment field

■ Diagnosis Codes 9 -12 added.
■ “Similar Illness Date” field removed.
51
Four fields added for
Diagnosis
Codes 9-12

■ AP - ANOT PYT RESP(another party responsible)
removed from “Related Causes Type” dropdown
list.
52

837P POSC Transactions
837P
Professional Claims
Extended Services Tab
53

■ New value added to Delay Reason Code list:
15 – Natural Disaster
54
New value added

■ “Type” field removed.
Former Service Facility types used:
• 77 – Service Location
• FA – Facility
• LI – Independent Lab
• Tl – Testing Laboratory
■ MMIS will default to 77 – Service Location in all
instances.
55

■ The “PMT – Payment” field removed from the
dropdown box in Claim Note Type.
56

■ Entire “Home Health Care Plan” section removed
■ Fields formerly in this section:
– Discipline Type Code
– Total Visits Rendered
– Certification Period Projected Visit Count
■ Data covered in other sections of POSC.
57

■ “Transport Code” field removed.
58

837P
Professional Claims
Procedure Tab
59

■ “Unlisted Procedure Description” field
stores and displays information in a panel.
60
Can receive 80 characters
of free text from Providers.
Displays information for
suspended claim review.

■ Providers can enter Diagnosis Cross-Ref values with up
to eight values per detail line (two values per box).
61
Can enter either single
or double-digit Diagnosis
Code in each box.
(System adds preceding
zero for single-digit
codes in each box.)
Codes entered in boxes 1
& 4 will concatenate.

■ “Units” field increased to 11 numbers with 3
numbers allowed to the right of decimal point
62
Length of “Units”
field increased.

■ “Additional Units of Obstetric Anesthesia” added
■ “Similar Illness Date” removed
63
.
Indicates need for
more anesthesia for
obstetric units

■ F2 – International Unit (Dosage Amount) removed
from Units of Measurement dropdown list.
64

■ Emergency field has “blank” or “Yes” value only.
– This field no longer required.
– Defaults to blank value.
65

■ Drug Identification Section added
■ Rx date appears only in 837P – not 837I
■ VY– Link Sequence Number added – when drug
has no prescription number
66
Only appears in 837P
New option
added

■ If you enter a value in one of these four fields –
the other three must also contain a value.
67

■ “Patient Count” field added
■ “Transport Code” field removed from this section
68
Indicates number of
patients transported

■ “ Ambulance Pickup Location” and “Drop-off
Location” data fields added
69

■ Home Oxygen Therapy Information section and
the following fields removed: Certification Type
Code, Aerial Blood Gas, Oxygen Test Condition,
Treatment Period Count, Oxygen Saturation,
Oxygen Test Findings Code 1-3.
70
Home Oxygen
Therapy
Section
removed

837P
Professional Claims
Attachments Tab
71

■ “Description” field removed from Attachments tab
■ List of Values updated on Report Type (top half)
72

■ List of Values updated on Report Type (bottom half)
73

837P
Professional Claims
Coordination of Benefits (COB) Tab
74

The Coordination of Benefits (COB) tab no
longer displays the following fields:
– Allowed Amount - calculated using payer paid
amount and coinsurance/deductible amt
(based on adjustment reason codes).
• Allowed amount is being calculated by
MMIS. Please refer to the HIPAA
Implementation Guide for allowed amt
calculation
75

Discontinued fields continued:
– Patient Responsibility Amount - This was a
duplicate field. Patient responsibility was
reported in the adjustment reason panel with
reason code (for example: 1 for deductible; 2
for coinsurance etc.)
– Subscriber Date of Birth removed
– Subscriber Gender removed
– Approved Amount removed
– Discount Amount removed
76

■ “Remittance Date” renamed from “EOB Date”
77
Renamed from “EOB Date” field

■ “Remaining Patient Liability” field added
78
Renamed from “Allowed Amount” field

79
■ “Total Non-Covered Amount” field added:
– When payer’s cost avoidance policy allows
providers to bypass claim submission to the
prior payer.
Amount Aids in
Claim Adjudication

■ User must enter an amount in either the “COB
Payer Paid Amount” field or the “Total Non-
Covered Amount” field (but not both).
80
Enter amount in this field
or in other indicated
“Amount” field (but not both).
Enter amount in this field
or in other indicated
“Amount” Field
(but not both).

■ Values updated on Claim Filing Indicator list
81
Values
updated

■ Release of Information list now indicates only two
values – I and Y.
■ Prior M, N and O values removed.
82
Indicates only two values – I & Y

■ Patient Signature Source Code List defaults to
blank.
■ Displays only one option for provider-generated
signature for absent patient.
83
Defaults to blank

■ “Group Name” field renamed from “Plan Name”
84
Renamed from “Plan Name” field

■ Select the Insurance Type dropdown list if
Medicare A or B is not the primary payer
85

■ Outpatient Adjudication Information no longer
restricted to Medicare. Any COB payer’s remarks
can be submitted here.
86
“Medicare” removed from title

837P
Professional Claims
Procedure Tab - COB Line Details
87

■ “Paid Units of Service” field increased to 11
numbers with 3 numbers allowed to the right of
decimal point
88
Length of
field increased

■ “Approved Amount” field removed.
– Approved amount is the same as the allowed amount,
with the difference being that the approved
amount was being reported at the line level and the
allowed amount was reported at the header level. This
field is calculated by MMIS.
89

835
Electronic
Remittance Advice
90
835 Transactions

835 Transactions
■ During testing, MassHealth will generate 835s for
all testing phases.
■ Claims that are reversed or voided will appear on
the 835 with a claim adjustment group code of
OA.
91

New 999 Acknowledgement Transaction
999
File Acknowledgement
92

New 999 Acknowledgement Transaction
 MassHealth will no longer support the 997
Acknowledgement as of January 1, 2012
 Receipt of a 999 acknowledgement file indicates
receipt and status of each segment of 5010
transaction testing
 The 997 Acknowledgement has been eliminated
 A 999 implementation acknowledgement is
generated for all batch files that do not fail and
includes interchange (ISA) errors
93

270/271 POSC Transactions
270/271
Eligibility Verification
Eligibility Transaction Search
94

270/271 POSC Transaction Screen
95
■ Last Name – This field increased from 35 to 60 characters.
■ First Name – This field increased from 25 to 35 characters.

96
■ Phone Number (day, night, cell) fields remain, but will
appear blank. These values were removed per guidance
from HIPAA 5010 regulations.

276/277 POSC Transactions
97
276/277
Claim Status
Inquire Claim Status

276/277 POSC Transaction
■ Last Name or Organization Name – This field increased
from 35 to 60 characters.
■ First Name – This field increased from 25 to 35
characters.
■ Phone Number (day, night, cell) Fields remain but will
appear blank.
■ HC Claim Status field displays EOB Code, Claim Status
Category Code, Claim Status Code and Entity Code.
■ Currently these fields will only show the original number of
characters indicated in 4010, if you are looking at a claim
submitted under 4010.
98

99
■ HC Claim Status field displays all EOB HC claim
statuses for all corresponding multiple EOBs.
 EOB Code – details explanation of benefits.
 Claim Status Category Code – indicates the
payer’s current system status of the claim.
 Claim Status Code – provides more
specific information about the claim or line
item.
 Entity Code – identifies an organizational
entity, a physical location, property, or an
individual.

■ HC Claim Status field displays all EOB HC claim
statuses and the respective HC status code and
description.
100
Displays EOB HC
Claim Statuses

101
■ Services Detail Screen displays a list of services
rendered for each claim as indicated by the
Service Code.

EVSpc Transactions
EVSpc Highlights
102

Eligibility Verification System (EVSpc) Changes
 EVSpc software is now modified to include HIPAA
5010 requirements. EVSpc is only supported on
Windows XP & Windows Vista.
 MassHealth does not recommend using Windows 7
to install EVSpc 5.0 software.
 If any issues arise using Windows 7, MassHealth will
not be able to provide support.
103

EVSpc Transactions
 All inquiries occur in Real Time.
 Can submit eligibility in either batch mode or as a single
inquiry.
 EVSpc 5.0 enables providers to verify MassHealth
member eligibility, claim status, primary care clinician
(PCC), managed care, long-term care and third-party
liability.
104

Eligibility Verification System (EVSpc) Changes
 Number of characters have increased for the
following fields:
 First Name – 25 to 35 characters
 Last Name – 35 to 60 characters
 Name Normalization – These changes are
effective January 1, 2012 in HIPAA 5010
105

New 5010 Standards for Electronic Health Care Transactions

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Editor's Notes