Transition/Compliance Plans for Medicare claims via 5010:

Date: December 30, 2011

The Centers for Medicare and Medicaid (CMS) recently issued further clarification regarding 5010 claims. They confirmed the need to have and submit a 5010 claims transition plan if you are not completely transitioned by December 31, 2011.

The important points are:

  1. All claims submitters must have a plan in place within 30 calendar days of their being notified by their Medicare Administrative Contractor (MAC).
  2. Providers who submit claims directly (i.e., no billing intermediary) should hear from their MAC about their transition plan.
  3. The notice re-states the current requirement for submitters (clearinghouses, vendors, and billing services who submit Medicare claims on behalf of providers) to test 5010 claims with the MAC.
  4. Medicare does not specify or advise on the transition/compliance plan other than to say that a plan should note what steps have been taken and remain to be accomplished for full 5010 HIPAA claims compliance.
  5. The plan must be approved by the MAC.
  6. If the plan is approved, you have until the 90 days ending April 1, 2012 to complete the transition to 5010 formats.
  7. If a practice had not submitted a plan by the deadline, Medicare FFS “may” direct the MACs to reject 4010 claims, but that “MACs have not been directed to reject 4010 claims at this time”.
  8. If you have submitted a plan, MACs will accept either 4010 or 5010 claims for the 90 day period.

We believe that your Transition Compliance plan should be sent to the person or office named on the MAC notice. If you have not received a notice, check with your claims submitter.

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