EDI 5010 standards update
Beginning Jan. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) mandates that all health care providers and payers must use the new HIPAA 5010 electronic data interchange (EDI) format to exchange key business transactional data.
- The 5010 format replaces the current 4010 version. To learn more about the 5010 mandate, visit the CMS website at www.cms.gov/Versions5010andD0.
-
You do not need to change your EDI setup to prepare for the 5010 format.
-
Changes in your NPI or billing provider setup including physical address will require that you contact Provider Services at the email and phone numbers below.
What's changing from 4010 to 5010
The 5010 standards are more specific on what data is needed, collected, and transmitted in a transaction. Understanding these changes and how they will affect your practice/facility will prepare you for a smoother transaction.
Some key changes include:
- Member contract number (a unique number for each member) must be placed in the 2000B loop as if the patient were the subscriber
- PO Box will not be accepted for the billing provider's address; must be a street address
- "Pay to" address is required when different from the billing provider
- 9-digit ZIP Codes are required for billing and servicing provider loops
- Diagnosis code reporting is separated
- NPI subpart use is clarified
- Anesthesia billing will require minutes as opposed to units or minutes
- ICD-10-CM and ICD-10-PCS qualifiers are added
- The new ICD-10 codes will be supported effective Oct. 1, 2013
Priority Health 5010 testing
- Only errata versions will be accepted for the 5010 transactions for both testing and production.
- Any employer group or TPA who wishes to send the 5010 version for the 834 enrollment transaction should contact the EDI department.
Claims testing
Priority Health is currently testing 837P and 837I claims in the 5010 format with our direct data exchange partners. If you send claims to Priority Health through a clearinghouse or other third party, you don't need to contact us. Your clearinghouse will test with you and with us separately.
COB claims and secondary claims may be sent.
Remittance file testing
835 remittance testing is currently underway. If you send your claims through a clearinghouse but you receive the 835 remittance files directly from Priority Health, contact our EDI staff at the email and phone numbers below.
Companion guides
With exception of the 270/271, Priority Health will not be publishing companion guides. We follow the HIPAA standards as published in the TR3 documents.
Compliance validation
Priority Health will be validating 5010 test files through a compliance checker from Ingenix. We will need to enforce full compliance through level 5. As we test outbound transactions, such as Medicare encounters, Medicaid encounters and payer-to-payer COB, we may need to increase our compliance to level 6 and/or 7.
Testing procedure
No appointment is necessary to send a test a file to Priority Health. To submit a test file:
- Send test files using the same method you use for your production files.
- Mark the ISA_15 element as "T." If you do not mark it as "T," it will load as a production file. No other separate identification is necessary.
- Test files can be any size and should contain live Priority Health data, not dummy data.
- After you submit a test file, email our EDI staff (address below) and include your contact information.
- We will send the notice of 5010 approval to the contact you identify in your email to us.
Schedule for the 5010 changeover
- Remittance testing (835 files) begins in Sep. 2011. We can only create a test 835 file from test claims.
- Production 5010 files will be accepted beginning in Oct. 2011.
- Both the 4010 and 5010 versions will be accepted until Dec. 31, 2011.
- 835 remittance files will be promoted to the 5010 version in production at the same time as your claim files. If you send a 4010 format claim file, we will still return the 5010 version of the 835 remittance file.
- Only 5010 formatted files will be used beginning Jan. 1, 2012.
5010 information contacts
EDI staff
Email EDISETUP@priorityhealth.com
Phone: 616 464-8686
Fax: 616 942-9932
Provider Services
Email provider.services@priorityhealth.com
Demographic updates: ph-providerinfomgmt-demographics@priorityhealth.com
Phone: 800 942-4765
ICD-10 contact
Email Joni.Wagner@priorityhealth.com
