HBMA Develops Standard Definitions for 5010 Readiness

For months, providers, health plans and others involved in the electronic claims submission industry have announced that they were ready to begin testing and/or processing transactions via the new 5010 standard. However, once moving into the testing phase, it became apparent to HBMA’s members that providers and health plans had different definitions of what it meant to be ready to submit and process 5010-compliant claims.

In response to the inconsistency of definitions we’ve found between providers, software vendors, clearinghouses and health plans, the HBMA ICD-10 Committee has developed standard definitions for 5010 readiness. We have also shared these definitions with Centers for Medicare & Medicaid Services (CMS) officials in a letter on October 10, 2011.

In our letter, we recommend the definition of ‘ready’ specifically include compliance with each published standard by the regulatory implementation date. Further, we strongly recommend that payors must be restricted to limited, standardized and approved companion guides, and only when absolutely necessary.

Under HBMA standards, providers and clearinghouses are “5010 ready” when they have successfully completed a production submission of claims (837) and received the associated remittance (835) for those claims in compliance with the 5010 specifications. Specific tactics include:

• Completion of all practice management system upgrades;
• Confirmation of successful testing with direct submission carriers;
• Confirmation of successful testing with clearinghouses where applicable;
• Confirmation of successful production submission of claims (837); and
• Confirmation of successful retrieval of the claims’ associated remittance (835).

By the same definitions, payors and clearinghouses are considered “5010 ready” when they have successfully accepted a production submission of claims (837) and returned the associated remittance (835) for those claims in compliance with the 5010 specifications. Specific tactics include:

• Completion of all system upgrades;
• Confirmation of successful testing with direct submitting providers;
• Confirmation of successful testing with clearinghouses where applicable;
• Confirmation of successful acceptance of production claims (837) submission; and
• Confirmation of successful return of the claims’ associated remittance (835). 

In presenting this standard definition of 5010 readiness to CMS, our goal is to provide a definition that will be accepted across the industry as a uniform standard. If all participants engaged in the transition from 4010 to 5010 agree on the meaning of ‘ready,’ the term will have more credibility and value for those communicating with each other. We hope our proposal will be favorably received by CMS. Given there are less than 50 business days before the implementation date of Jan. 1, 2012, we hope their swift action on this issue will help to limit industry confusion during this critical transition period.