“I work for a provider who doesn’t submit claims electronically, and doesn’t plan to start because he’s retiring in a few years. How does 5010 affect providers who still submit claims on paper?”
Search for the answer and you’ll find a lot of confusion. Many, for example, are under the impression that after Jan. 1, 2012, all payers are obligated to ban paper claims and allow only electronic transactions. That’s not quite true.
Here’s the short answer to the question: If you’re currently allowed to conduct your claims transactions on paper, 5010 does not affect you.
It’s as simple as that. So, why all the confusion?
As I see it, it boils down to two reasons. The first is because very few providers are allowed to conduct paper claims transactions. The second is because most healthcare organizations are trying hard to encourage electronic transactions. They want to keep paper claims as exceptions rather than the rule, which makes a lot of sense from an efficiency standpoint, but makes it hard to find much information about paper transactions.
So, for the record, these are some of the facts you should know about 5010 and paper claims:
- The HIPAA regulations mandate national standards (including 5010) that apply to electronic transactions only. As a 5010 toolkit from the American Medical Assoc. (AMA) succinctly explains: “The HIPAA provisions for standardizing transactions are specific to transactions conducted electronically…Transactions conducted on paper, through a dedicated fax machine, or via the phone are not subject to the HIPAA provisions.”
- Medicare, however, requires the use of electronic claims except for certain rare exclusions, such as those providers with fewer than 10 full-time equivalent (FTE) employees. (See section 90 of the Claims Processing Manual, Chapter 24, here.)
- The HIPAA standards apply to electronic transactions with all payers, not just Medicare.
In other words, most providers filing claims with Medicare and other payers will need to be compliant with 5010. However, those providers or payers who happen to meet certain exceptions to the HIPAA requirements also aren’t subject to the HIPAA 5010 transaction standard. Those few will be able to continue filing paper claims just as they currently do—at least for now.