5 Most Common 5010 Transaction Rejections
After extensive testing of 5010 claims transactions with Medicare, Medicaid, Blue Cross Blue Shield and commercial payers, clearing houses have identified the 5 most common rejections that practices need to fix to insure that there claims will pass the new 5010 edits.
1. Billing Provider Address – Claims are rejecting because the field contains a PO Box or Lock Box address.
2. 9 Digit Zip Code – required for the billing provider. This can be obtained by going to the US postal services website.
3. Provider Accept Assignment Code – claims will be rejected that do not contain a value value for the payers that are live for 5010 transaction (if Live the assignment needs to be “A” for assigned).
4. Priority (Type) of Admission or Visit – payers who are live for 5010 transaction will need a value code for the admission or visit priority. Contact your billing software vendor or your clearing house to insure that you are providing this priority type in the electronic transaction file.
5. Drug Quantity – the CTP segment has been modified to require the drug quantity when a drug is billed. Contact your billing software vendor to insure that the drug quantity is being included in the electronic claims transactions.
Practices must adopt the latest version of the HIPAA electronic transaction standards, Version 5010, by Jan. 1, 2012. These electronic transaction standards include claims, insurance eligibility verification, remittance advice and others.
CMS announces implementation of new fraud-fighting technology
Beginning July 1, the Centers for Medicare & Medicaid Services (CMS) will begin using new predictive modeling tools to root out fraudulent Medicare claims. CMS says its approach is based on using real-time data to identify fraud as credit card companies do. Last year’s Small Business Jobs Act of 2010 provided funding – $100 million – for CMS to implement this technology.
The agency contracted with Northrop Grumman to develop processes to review claims by beneficiary, provider, service origin or other patterns and identify potential problems. Claims that raise concerns will be flagged and assigned a “risk score,” which will determine the agency’s next steps before it pays the claim. While CMS originally planned to roll out the program gradually, it announced last week that it will go nationwide on July 1.
How do practices know that this new technology will not interfere with timely payment of legitimate claims, if CMS won’t disclosed any detailed information regarding how the technology will be used. CMS usually rolls new technolgy out to a pilot group first. Not this time, they are rolling this out nationwide. I see cash flow issues for those physician practices who treat large volumes of Medicare & Medicaid patients.
To date, the government has not provided adequate details on this program. Click Here for the official CMS press release.
