5010 Transition
Changes between 4010 and 5010, from the Provider point of view
This document addresses some of the changes a provider can expect with 5010. This is not a complete list; it highlights some of the changes that will affect providers most directly.
- P.O. Box addresses will no longer be allowed in the billing provider address section of the claim. This means that in the part of the claim where you indicate the group (or your name, if you are a sole practitioner), payers will be looking for an actual street address. HOWEVER, you may still use a P.O. Box in the “pay-to” section of the claim.
If you use Practice Management software and you are not sure where to check this information, give your vendor the following and they can direct you towards the correct fields:
The location of the billing provider address in the electronic bill is the 2010AA loop.
The location of the pay-to address in the electronic bill is the 2010AB loop.
If you use UHINt 2.5 to hand-enter your claims, the billing provider address is in box 33 of the professional form, box 1 of the institutional form, and box 42 of the dental form.
The pay-to address will be an available field in time for 5010 testing.
NOTE: for some payers, this change makes it more important that you send the address that is on file with the payer. Please contact individual payers to verify the correct address.
- The Tax ID should no longer be put in the Rendering Provider area. If you list a rendering provider, please provide the National Provider ID (NPI).
Information for your vendor: The output location is the 2310B loop in the electronic bill.
If you use UHINt 2.5 to hand-enter your claims, this is the “Type of Identifier” in box 31 of the professional form.
- Zip codes in the billing provider area must include the 4-digit extension.
- If you have sub part NPI’s, the Billing Provider is considered the highest level with a unique NPI. This means that if the patient was treated in a department or satellite clinic with its own NPI, the department/satellite clinic becomes the billing provider in the claim.
- The subscriber will be considered the highest level with a unique ID. If the patient is not the policy holder, but still has a unique ID from the insurance company, that patient is considered the subscriber in the claim.
- Eligibility will become more robust, and most of the changes will be mandated for all payers. These changes reflect what many of the Utah payers have already implemented.
Some additions include:
Deductible accumulation amounts (if available)
Primary care provider (if applicable)
If a pre-existing condition is in effect, Pre-Existing Condition indicator must be returned
More detailed information for specialties
General In and Out of Network benefits
- Two reports are being replaced:
The 997 will be replaced by the 999. This new report allows for totals of accepted claims and provides information about rejected claims. This can assist with reconciliation.
The 277FE will be replaced by the 277CA (there will be minor content changes).
- If you have a Practice Management system, it must be 5010 compliant by January 1, 2012.
Your vendor will probably test with you before you test with any payers.
Your software may look different, depending on your vendor. To prepare yourself, you may want to ask your vendor about any changes.
Last Updated: 19 May, 2011
