The healthcare industry has been using HIPAA 5010 standards to transmit electronic medical claims for a few weeks. How’s that working for your practice? Are you seeing denials? Do you know what to be looking for and get the data fixed? While it’s tempting to assume that no news is good news, a lack of response doesn’t mean there is not an issue. Make sure you watch out for any medical claim rejections and denials and fix them as quickly as possible. Some of the problems that could be causing rejections or denials includes:
- National Provider Identifiers (NPI) need to be used, not an employer’s tax ID or Social Security number.
- HIPAA 5010 requires that a street address – not PO Box, be used on all medical claims.
- Providers can use a PO Box for a billing address that receives reimbursement checks. But make sure the payers have that on file and are using it.
- Speaking of addresses, providers need a nine-digit zip code with the billing and physical addresses.
- HIPAA 5010 allows as many as 12 diagnosis codes on each claim, but each specific service can only have four codes.
- Any claim using an unlisted Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code also needs a code description.
- Healthcare providers must submit a Medicare Secondary Payer (MSP) indicator on the primary and secondary claim when Medicare is the secondary payer.
- Drug quantity and unit of measurement are required when a National Drug Code (NDC) is listed.
- All ingredients in a compound prescription must be listed with a HCPCS code.
In addition to watching the number of denials or rejections, make sure the reimbursements match what you expect. Just because the claims get out the door, doesn’t mean they it will be processed correctly for reimbursement. There are many aspects to the claim process and all must be evaluated.
We hope you are having success with the transition from 4010 to 5010!