How Paper Claims Will Be Impacted by 5010
We’ve all seen—or asked—a question like this: 
“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.
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3 Responses for "How Paper Claims Will Be Impacted by 5010"
I think you hit the nail on the head with your second point. Healthcare organizations are trying hard to encourage electronic transactions because it makes their own in-house operations that much more efficient. There is a lot of buzz and talk about electronic transactions, so information about filing paper claims gets pushed aside.
We are having an issue with paper claims…there are some claims we need to send paper (especially with workers comp). We have a physicial address for the “billing provider address” and our PO Box for the “pay-to address” loops per 5010 rules. But when claims are printed on paper, the “billing provider address” is printed in 33B and not the “pay-to address”. We have an workers comp payer that is not paying claims because the “billing provider address” is not on file with them and is not our PO Box.
Do you have any suggestions on how to deal with issues like this?
Thanks!
Jessica, thanks for the question. How Box 33 is completed has been confused somewhat with 5010 electronic requirements that the practice street address must be a physical address and PO Boxes must be reported separately as the “pay-to” address. If the paper form is completed using information from an electronic 5010 claim, the question is which address should be printed? The official NUCC instructions indicate that the physical address should be printed in box 33; however, many payers use the information in Box 33 to locate or verify practice information, which still may be the “pay-to” address in the payer’s system, and/or to actually determine where remittance or remittance information should be sent.
Unfortunately, there probably isn’t one correct answer for all payers. The important questions are does the payer use the address in Box 33 to remit payment or does the payer use the address in Box 33 only for verification? If the payer uses the information in Box 33 to determine where to remit payment, then it would be necessary to work with your claim printer or software supplier to print the “pay-to” address in Box 33 – perhaps on a payer-by-payer specific basis. If, on the other hand, the payer uses the information in Box 33 only to verify practice information, it would be better to continue printing your physical address in Box 33, but work with the payer to both set up the new physical address for verification and also to make sure to provide the address where remittance should be sent.
Finally, I would encourage you to verify from time-to-time whether the claims may be sent electronically. Many payers allow – and more states are requiring – electronic workers comp claims processing.
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