Don t Get with 5010

1. Don�t Get with 5010

3. Version 5010 835 - Payments Version 5010 270/271 � Eligibility Providers Payers

4. Claim Status code list has changed significantly. Claims Status Code location at CLP02 identify the status of the entire claim as assigned by the payor. Claim status code 4 - Denial definition changed Codes removed from list Notes added for clarifications.

5. Provider Redefinition of Claims Status 4 will make it more difficult for the provider to distinguish between a true denial or claims with high deductible amounts. Claim Status Code 4 should only be used when the patient cannot be found on the payer system.

6. Allows for the provision of a technical contact and the payer�s website where further policy information can be found. Not required.

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8. Allows for Remit delivery data to be provided when both the EFT and 835 are sent to a financial institution. Not Required

9. Additional Clarity for Balancing Balancing does not change

10. Claim Overpayment Recovery is Clarified Providers may still elect to negotiate specific methods in their contracts.

11. Provider It does help to know that there is a reversal It is problematic because method of recovery is left to Trading Partner Agreements. Provider does not have a voice in recoup method.

12. Remark Code Usage Situational Required when reason code is insufficient to explain denial

13. Provider Very beneficial in reporting for the provider so that an automated determination can be applied to the claim Will reduce call volume and the need to call for more information.

14. 5010 extends the definition of the subscriber identifier to all downstream transactions. 278, 837, 276/277, 835

15. Provider This could be the single biggest advantage to the providers. Currently many providers require the subscriber DOB on the 837, but do not provider it in the eligibility response for the dependant leading to phone calls, denied claims and appeals. OR paper claims.

16. Provider Would require programming to enable upload and storage of data to enable its later submission on claims Where patient has multiple coverages it could require data storage at the insurance level rather than the patient level

17. New required alternate search options using member ID and DOB or member ID and name

18. Provider As above some payers require an exact DOB match, yet may have the DOB stored incorrectly. A search using the ID, last name and first would provide the payer DOB.

19. Additional Service Type Codes and Requirements. 45 New Service Type codes have been added. New requirement: If information source receives a STC 30 or one they do not support, 10 codes must be returned if they are covered at the plan level. 1 � Medical 33 � Chiropractic 35 � Dental 47 � Hospital 86 � Emergency Services 88 � Pharmacy 98 � Professional Office Visit AL � Vision MH � Mental Health UC � Urgent Care

20. Provider Important in environments where physician and hospital events are covered by different insurers. A generic STC 30 query to a payer would require a response of both 47 hospital and 98 physician if covered. Lack of response on any of the 10 could be interpreted as no coverage for the service type.

21. Provider Ambiguity remains for financial responsibility. 5010 does not mandate content on response to patient responsibility. Benefits remaining or used are still unknown

22. Requires the return of PCP where applicable

23. COB Information

24. Don�t Get with 5010