Prepared by Cathi Hammond, Medical Business Consulting, for the Minnesota Chiropractic Association Page 1 electronic claims through a clearinghouse.
Section 1: How are you submitting your claims now?
Ask your clearinghouse: “Am I currently submitting my claims to you in the 5010, 4010, or print image format?”
If the answer is 5010, skip to Section 4: Prior to Testing
If the answer is 4010, skip to Section 2: Is Your Billing Software 5010 Ready?
If the answer is “print image” or some other format, you need to upgrade your billing software to a 5010 version ASAP to ensure that you are able to submit compliant claims by 1/1/2012. There are some new fields in the 5010 version that you won’t be able to utilize with print image submission so it’s in your best interest to upgrade.
If, for some reason, you are not able to upgrade your billing software to a 5010 version right now, you need to confirm that your clearinghouse is able to convert your claims for you.
If your clearinghouse tells you they can “up-convert” your print image claims to 5010, ask if they have successfully tested this with multiple payers. If so, you could stay with your current software version for a little while longer (but it’s not recommended). However, you will need to upgrade your software by early 2013 to accommodate the ICD-10 codes. You are just delaying the inevitable, and probably creating more work for you and your staff, by not upgrading now.
If your clearinghouse has not successfully tested up-converting print image claims with multiple payers, upgrade your software to 5010 now and save yourself a lot of aggravation in 2012.
Note: most clearinghouses will be “up-converting” print image claims to the 4010 format first before they are “up-converted” to the 5010 format. Not only will this delay getting the claims to the payer by 1-2 days, but it also leaves a lot of cracks for your data to slip through which could cause claim rejections and/or denials. The fewer conversions your data goes through, the better your chances are of successfully submitting claims and getting paid.
Prepared by Cathi Hammond, Medical Business Consulting, for the Minnesota Chiropractic Association Page 2 Section 2: Is Your Billing Software 5010 Ready?
Ask your software vendor if the billing software you are currently using is 5010 ready.
If the answer is “YES” skip to Section 4: Prior to Testing
If the answer is “NO”, ask if they have a 5010 ready version available. o Ask if the 5010 ready version also accommodates the new ICD-10
codes (that are required Oct. 2013). If so, it is highly recommended that you upgrade your program now.
o If the newest version of your software is 5010 ready but does not yet accommodate the new ICD-10 codes, you might be able to hold off upgrading until the next upgrade is available (but only if you are currently submitting your claims in the 4010 format – see Section 3). If a 5010 version of your software is not yet available, ask your vendor when
they anticipate it being ready. If their release date is later than September 2011 you should start thinking about a “plan B” to make sure you are able to submit compliant claims (and get paid) by January 2012.
Section 3: Currently Submitting in 4010 Format
You need to determine if your clearinghouse can convert your 4010 claim submissions to the 5010 format.
Ask your clearinghouse if they have successfully tested “up-converted” 4010 formatted claims to the 5010 format.
If their answer is yes, skip to Section 4: Prior to Testing
If your clearinghouse has not successfully tested “up-converting” 4010 claims, ask when they anticipate having their internal testing completed so you can start testing your claims. If they don’t have an estimated date, or it’s after September 2011, you need to upgrade your billing software to a 5010 ready version as soon as possible to by-pass the 4010 “up-converting” process. You need as much time as possible to test and make adjustments to your 5010 claims to ensure you are ready by 1/1/2012.
Prepared by Cathi Hammond, Medical Business Consulting, for the Minnesota Chiropractic Association Page 3 Section 3: Currently Submitting in 4010 Format (continued)
Even if your clearinghouse is able to “up-convert” your 4010 claims to 5010, it is still advisable to upgrade your billing software to a 5010 Ready version to avoid any problems.
The only reason to delay upgrading your billing software to a 5010 Ready version is if the 5010 version is not yet able to accommodate the new ICD-10 codes and you would have to pay for 2 software upgrades.
Section 4: Prior to Testing
You need to make sure the following items are compliant with the 5010 standards in your billing software:
The Billing Provider address on your claims must be a physical street
address. Post Office Boxes are no longer allowed. You can still use a P.O. Box in the Pay-To address field. Check with your software vendor if you are not sure how to make this change in your system. Make any necessary changes with your clearinghouse, too.
The 9 digit zip code (Zip+4) must be used in all of your clinic addresses (Provider, Pay-To, Facility, etc.). You are NOT required to use Zip+4 in the patient, subscriber, or insurance address fields. You can find your 9 digit zip code at www.usps.com under the “Zip Code Search.” Make any necessary changes with your clearinghouse, too.
Determine which patients need to have the subscriber information corrected in your system and make the appropriate changes. If the patient is a
dependent and has a unique ID#, the patient information should be used in the subscriber field even if the parent or spouse is the actual policy holder. Conversely, if the patient’s ID# is the same as the policy holder’s, the policy holder’s information would be used in the subscriber field. In this case, you will also need the policy holder’s date of birth.
Make sure each provider in the clinic is listed in the Medicare PECOS system. You can check this at www.oandp.com.
If you use referring providers on your claims, make sure you have an NPI for each of the referring providers, and that each referring provider is listed in the Medicare PECOS system. You can check this at www.oandp.com.
Prepared by Cathi Hammond, Medical Business Consulting, for the Minnesota Chiropractic Association Page 4 Section 5: Testing
Ask your clearinghouse when you can begin testing your claims to make sure they won’t be rejected. The sooner you begin testing, the more time you will have to make any necessary adjustments to your program and re-test before the January 2012 deadline.
You will need to contact your clearinghouse to arrange submission of your test claims. Each clearinghouse works differently, so you need to coordinate everything with them – including how many claims and/or batches they want you to test.
The purpose of this testing is to make sure your claims will pass through your clearinghouse’s edits and not be rejected, so your clearinghouse probably won’t forward the claims to the payers for processing. Therefore, the claims you submit for testing should not be production claims that need to be
forwarded to the insurance company for payment. Instead, submit claims that have already been submitted and paid.
Your test batch should contain a wide variety of claims using many variables, such as:
Male and female patients
Patients who are the subscriber and patients who aren’t the subscriber At least one claim for each of the major payers (Medicare, BCBS, Medica,
HealthPartners, ChiroCare, HSM, Preferred One, auto, work comp, etc.) Claims with modifiers and claims without
Claims with Prior Authorization numbers and claims without Claims with 4, 8, and 12 diagnosis codes
If you have more than one provider in your office, send test claims for all providers.
Prepared by Cathi Hammond, Medical Business Consulting, for the Minnesota Chiropractic Association Page 5 Section 6: Going Live and Beyond
Once you have passed the testing phase, ask your clearinghouse when they plan to “go live” and submit 5010 claims. Many payers are anticipating being ready to accept 5010 claims this fall, and clearinghouses are planning on sending 5010 claims to the payers as they become ready.
In most cases, once you have passed the testing phase your clearinghouse will be able to accept all of your claims in the 5010 format and forward them to the payers that are ready. Ask how your clearinghouse plans to handle this process.
If you submit claims to payers that aren’t ready to accept 5010 claims yet, will your clearinghouse “down-convert” those claims to 4010 before forwarding them to the payer?
Even if you have successfully tested dozens of claims with your clearinghouse, you may run into problems after 1/1/2012 (or when the payer goes live with 5010). The test claims you sent to your clearinghouse were only tested within your clearinghouse, and were not forwarded to the payer for additional testing. This test method will likely eliminate 90% or more of potential problems, but it may not eliminate all of them.
Keep track of which payers are accepting 5010 claims and watch those claims closely (your clearinghouse may have a list of payers who are 5010 Ready). The first several months will be the time when claims could easily slip through the cracks and end up floating around in cyber-space, never to be seen again. Promptly check all of your clearinghouse reports to make sure the claims are
accepted for processing by the payer.
If you haven’t received payment on a claim within 30-45 days, follow up on it right away.
Remember, electronic remits are also changing to the 5010 format so be sure to check your remits carefully for erroneous denials.
If you normally auto-post your electronic remits, make sure you review the paper copy first to verify that everything is paid correctly. If you receive an erroneous denial, make sure it isn’t written off during auto-posting. It’s also likely that you will need to hand post some remits for awhile.
Prepared by Cathi Hammond, Medical Business Consulting, for the Minnesota Chiropractic Association Page 6 Section 6: Going Live and Beyond (continued)
Appeal all erroneous denials as soon as possible. Keep in mind that errors will happen so the payers will likely be flooded with appeals during the first 3-6 months of 2012. Anticipate long delays in processing appeals for payment. If an appeal has not been paid within 60 days, follow up with the payer to make sure they received it. If your appeal wasn’t received (or was lost), checking on it after 60 days will still give you time to submit another appeal within the payer’s timely filing requirements.
Continue to monitor your claims carefully throughout all of 2012 and 2013. A claim that processed successfully one month may not process successfully the next month since payers will be continually adding new edits to their systems. Medicare has addressed the issue of crossover claims with trading partners, but
actual testing and correct adjudication have not occurred – and may not occur before the end of 2011. Expect errors on crossover claims and payments from secondary payers. You may need to submit secondary claims yourself, even if your Medicare remit indicates the claim was crossed over.
You should anticipate many ups and downs in claims processing and payments within the next 3 years – until version 5010 and ICD-10 have been successfully implemented. Plan accordingly.
