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Be Aware: Four Key Changes to Watch for in Version 5010

The transition to Version 5010 may require your practice to make many changes in the way you submit claims, but the following four requirements are especially important to acknowledge and start thinking about now. Giving consideration to these changes and beginning communications with payers about them is something you can do right now to help lay the groundwork for a successful 5010 transition.

Change 1: Consistently enrolling National Provider Identifier (NPI) subparts. If your practice has multiple NPI subparts, you need to make sure you’ve enrolled them consistently with all payers using the lowest level enumeration. In addition, for payers that do crosswalk lookups, you should verify that the claim’s practice name and address matches what the crosswalk contains. These two efforts can help avoid enrollment problems and realize consistent reporting.

Change 2: Correctly reporting Post Office (P.O.) boxes. In Version 5010, practices can no longer use a P.O. box as the primary billing address. If you have a P.O. box, you’ll need to report it separately in the “pay-to” provider field, in addition to reporting a physical street address in the “billing” provider field. Make sure your existing practice management systems can support this change; if it can’t, check that work is underway to ensure such support is in place by each payer’s scheduled implementation time.

Change 3: Reporting dependents as subscribers. Some payers—including some Medicare and Medicaid plans as well as smaller payers and plans—choose to assign a unique subscriber identification number to the dependents of enrolled members. In these cases, you must report the dependent as a subscriber. It’s important to know which payers assign dependents a unique ID so that you can complete your claims appropriately. If you don’t, claims may be rejected, resulting in significant financial ramifications. This seemingly minor detail may have a big impact once 5010 goes live. By starting to have conversations with payers now, practices can head off possible denials due to inappropriate dependent reporting.

Change 4: Identifying the referring provider by name. If your practice currently reports a referring provider using the name of the organization in which he or she works—Acme Hospital, for example—you’ll need to start reporting the provider as an individual—such as “Dr. John Smith.” While many practices already do this anyway, it’s good to know what your organization’s current approach is to ensure compliance with the new requirements.