Claims Transmission ANSI 5010
What is ANSI 5010?

ANSI 5010 is the new version of HIPAA transaction standards that regulates the electronic transmission of healthcare transactions. The 5010 standards will replace the existing 4010/4010A1 version of HIPAA transactions and address many of the shortcomings in the current version, including the fact that 4010 does not support forthcoming ICD-10 coding. The Centers for Medicare and Medicaid Services (CMS) requires that all entities covered under HIPAA conform to the new 5010 standards by January 1, 2012. Similar to the National Provider Identifier (NPI) transition, practices will need to upgrade their practice management solution in order to be compliant with ANSI 5010.

Who does the ANSI 5010 change affect?

The ANSI 5010 change affects physicians, payors, software vendors and clearinghouses/ third-party billers.

When must the transition to ANSI 5010 be completed?

By January 1, 2012, practices will need to complete electronic transactions in an ANSI 5010-compliant format. These electronic transactions include claims, eligibility inquiries and remittance advices. Failure to comply may result in denied claims, slower payments and increased customer service issues.

What is the urgency to upgrade my practice management system?
These changes affect the amount of data and the way data is stored in the systems as well as your practice workflow. If you are on an older version of software, the implementation of the compliant versions will be more complex and time-consuming than previous upgrades. In addition, testing of the new ANSI 5010 standards has already begun. By upgrading now, you can take advantage of the testing period an

Frequently Asked Questions

What healthcare IT incentives are included in the American Recovery and Reinvestment Act?
As part of the American Recovery and Reinvestment Act, the U.S. government will invest more than $19 billion to modernize and accelerate the use of health information technology – particularly electronic health records (EHRs) – by hospitals and physicians.

Who or what kinds of organizations will benefit from the healthcare IT incentives?

The incentives primarily benefit hospitals and office-based physicians. They are designed to reduce healthcare costs by accelerating the use of IT to improve quality, safety and efficiency. Ultimately, patients and caregivers also will benefit from the automation and connectivity enabled by EHRs.

What is the potential financial benefit of the healthcare IT incentives to physicians?

Each office-based physician who meaningfully uses a certified EHR could receive up to $44,000 (Medicare) or $64,000 (Medicaid) in governmen funding. Office-based physicians practicing in rural or underserved areas would be eligible for up to $48,400 in Medicare incentives. It's important to note that these figures represent the maximum allowable incentives under the Medicare and Medicaid programs, and that physicians may only qualify for either the Medicare or the Medicaid funding, but cannot qualify for both.

When will the payments be made?

Funds become available for office-based physicians on January 1, 2011 (and are eligible to apply through January 1, 2012 and still receive full benefits). Providers should begin planning as soon as possible to allow time to achieve meaningful use of certified solutions during this time period.

Are there additional incentives for office-based physicians to adopt in the early years of the program?

Office-based physicians' maximum allowable Medicare incentive for the first year of meaningful use is increased by $3,000, from $15,000 to $18,000, for meaningful EHR use in 2011 or 2012. This "early adopter" incentive raises the total amount physicians can qualify for from $41,000 to $44,000. A benefit for office-based physician early adoption does not exist under the Medicaid incentive program.

What are the penalties if healthcare providers do not implement an appropriate amount of technology and reportquality data by 2015?

For office-based physicians who do not adopt such technology by 2015, Medicare payments will be reduced by the following factors in the years specified:
•2015: One percent
•2016: Two percent
•2017 and beyond: Three percent
•2018 and beyond: HHS Secretary may decrease one additional percent/year (max of 5%) if 75% of officebased
physicians don't adopt technology by 2018

Who qualifies as an eligible professional?

"Eligible professionals" under the Medicare HIT incentive program are limited to physicians as defined in the Social Security Act (§1861(r)), which includes:
•A doctor of medicine or osteopathy
•A doctor of surgery or of dental medicine
•A doctor of podiatric medicine
•A doctor of optometry
•A chiropractor
To receive Medicare incentive payments, the physician must: •Not be hospital-based;
•Demonstrate meaningful use of a certified EHR; and
•Submit Medicare Part B claims of at least 133% of the maximum incentive for a program year to qualify for the maximum incentive payment.
The Medicaid HIT Incentive program expands the definition of "eligible professionals" to include: •Certified nurse mid-wife
•Nurse practitioner
•Physician assistant (under certain circumstances)
To receive Medicaid incentive payments, eligible professionals must: •Not be hospital-based;
•Demonstrate meaningful use of a certified EHR; and
•Treat a patient population, of which at least 30% receive medical assistance (or 20% if the physician is a pediatrician). Although the incentives are not dependent on the eligible provider being a participating Medicare provider, the incentive amounts available to any provider is the lesser of 133% of their annual billed Medicare Part B charges or the maximum payment specified for the year in the regulations. (For example, a provider would have to bill $16,000 in Part B charges in order to qualify for a year in which the maximum allowable incentive payment is $12,000.) There are no distinctions between specialty and primary care physicians in terms of the incentives, EXCEPT that hospital-based physicians do not qualify for the physician incentives.

Do hospital-based physicians qualify?

The legislation specifically states that hospital-based physicians do not qualify for the Medicare or Medicaid EHR incentives.

Do physician assistants, nurse practitioners, etc. qualify for the incentive?

Certified nurse mid-wives, nurse practitioners and physician assistants will not qualify under the Medicare provisions. These providers can receive Medicaid incentives provided that at least 30% of their patients receive medical assistance.

Who qualifies for the additional 10% rural health incentive for office-based physicians?

An "eligible professional" who predominantly furnishes services in a geographic area that is designated by the HHS Secretary as a health professional shortage area may receive a 10% increase in their annual payment.

What is meant by "meaningful use" of healthcare IT?

Funding and incentives are tied to "meaningful" use. While no one yet knows the full definition of meaningful use, preliminary descriptions include the following: An eligible professional shall be treated as a meaningful EHR user for a reporting period for a payment year if the followingrequirements are met:
•Meaningful use of certified EHR technology. The eligible professional demonstrates to the satisfaction of the HHS Secretary, that during such period the physician is using certified EHR technology in a meaningful manner. The certified EHR shall include the use of electronic prescribing as determined to be appropriate by the HHS Secretary.
•Information exchange. The eligible professional demonstrates to the satisfaction of the HHS Secretary that during such period such certified EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination.
•Reporting of measures using EHR. Using such certified EHR technology, the eligible professional submits information for such period, in a form and manner specified by the HHS Secretary, on such clinical quality measures and such other measures as selected by the HHS Secretary. The HHS Secretary shall seek to improve the use of EHRs and healthcare quality over time by requiring more stringent measures of meaningful use selected under this paragraph.

Will the incentives be applied to systems already in use, or will they be applied to the purchase of new systems only?

The incentives are available to meaningful users of certified IT systems described in the legislation regardless of when they were implemented. The qualifier is the date at which the eligible provider can demonstrate meaningful use of the certified technology.

To qualify for the healthcare IT incentive, the legislation calls for the use of certified systems. What certification criteria will be used?
The legislation does not name a specific certification process or criteria. Industry experts believe there is a likelihood new certification requirements will be based on the standards that have been adopted by CCHIT.

National Provider Identifier (NPI)

Beginning May 23, 2007, any covered entity that wishes to submit electronically to Medicare, Medicaid, Medi-Cal, or any of the large insurers must have obtained an NPI from the National Plan & Provider Enumeration System (NPPES).