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Making the Grade: How Payers Are Handling the 5010 Implementation

I’m a firm believer in learning from every opportunity that presents itself. The 5010 transition is one such golden opportunity, especially for payers.

In looking at how payers have responded to the HIPAA 5010 implementation, I’d say performance has been mixed. On one hand, many larger payers have been on top of the numerous technical aspects of 5010 and have been quite persistent in reaching out to clearinghouses and practices. They have done a good job getting ready, technically speaking, well in advance of the different conversion dates.

On the other hand, communication about some of the details associated with 5010 has not been as effective. One of the largest communication issues centers on the absence of documentation about payer requirements for “situational use” claim fields.

These fields are just as they sound—they are filled out based on the particular situation at play. Providers must only use situational claim fields if the situation warrants it. Claims submitted with one of these fields filled out unnecessarily have been rejected. Conversely, if a claim requires information in a field and it is not present, a rejection is also automatic.

As I mentioned before, most payers have not provided adequate documentation about their requirements for when to use these fields, or what information to include in them. In fact, many have lacked guidance even for their own support staff. This has led providers and clearinghouses to make educated guesses about what information to include on claims, often resulting in rejections.

Overall, one of the reasons practices have seen an increase in the number of rejections with 5010 is because of poor payer communication regarding this critical issue. However, an opportunity for improvement still exists.

Payers now have an opportunity to address this documentation issue with future transitions. Going forward, it would be helpful if payers began offering clearer details regarding what claim information they require and when they require it. As a result, providers could have a greater understanding about payer specifications—and increase their chances of following the rules appropriately.