ANSI 5010: Common Rejections‏

The ANSI 5010 standards for electronic healthcare claims went into effect on January I, 2012. Payers – including Medicare, TRICARE and some state Medicaid plans – are currently rejecting claims that are not in the 5010 standard format. Rejections typically occur because of the fields or data elements listed below.

  • 9-digit ZIP code for the billing provider and service facility location: The 9-digit ZIP code can be easily looked up on the US Postal Service web site. It must be populated on the 5010 claim. If the last four digits are not populated on the 5010 claim, the clearinghouse likely will put in four default numbers. However, we are hearing from RelayHealth (which is using 0000 as the default) that many payers are rejecting claims with a default 9-digit ZIP code. The best practice is to capture the 9-digit ZIP code in the practice management system (Medisoft Version 17 or Lytec 2011) so that the additional digits are populated correctly on the 5010 claim.
  • Loops 2010AA, 2310C and 2420C/Data Element N403

ansi-5010-9-digit-zip-code-provider.PNG

ansi-5010-9-digit-zip-code-facility.PNG

  • Pay To Address:  PO boxes are no longer allowed in the practice/provider loops/segments. PO Boxes must be separately sent in the Pay-to fields. 
  • Professional Loop 2010AA, Data Elements N301 and N302
  • Special Characters: Do not use #, :, ‘, - in any fields.  The most common character is the # sign. Instead of using this for suite numbers or apartment numbers, spell out “number” or use “apt.” or “ste.”
  • NDC numbers: With 5010 NDC numbers are required on ALL injections. NDC numbers must be 11 characters long. A leading zero must be added if the NDC number is 9 or 10 digits in the segment. It must be in a 5-4-2 format.

When entering a referral provider that is an agency:


i.e.  Fayetteville Family Pediatrics
 
*The entire practice name, "Fayetteville Family Pediatrics" must all be in the "last name" line.  Nothing needs to be entered in the "first name" line.
 
*After the information is entered on the address tab and the Referring Providers ID tab is being entered, this is what is needed for Medicaid insurance carrier:

*Insurance Carrier - needs to be chosen for Medicaid with CA
 *Entity Type - NON PERSON
 *National Provider ID

When entering a referring provider that is a person:
 
i.e. Dr Larry Byrd
 
*Byrd would be the last name
*Larry would be the first
*MD would go in credentials
 
*After that info is added, on the Referring Providers ID tab - the following should be done:
     *insurance carrier - NC000 - needs to be chosen for Medicaid with CA
     *entity type - PERSON
     *National Provider ID

inst: hospital, group home, and bills with a UB-04

pro: individual or practice, bills with 1500

Common 5010 Professional Rejections and Requirements

RelayExchange™ Transaction Services
Reminder: You must comply with these updates to avoid rejections

RelayHealth has been actively testing 5010 claim transactions with Medicare, Medicaid, BlueCross BlueShield, and commercial payer lines of business. Through our extensive testing we have identified that each payer line of business is continuing to reject test claims from providers because they do not meet 5010 Errata requirements. You are responsible for making updates to your current production environment to ensure your smooth transition to 5010 production standards.

National Provider Identifier (NPI)

  • The NPI of the organization health care provider or its subpart is reported as the Billing Provider in Data Element NM109 of Loop 2010AA.*
  • If the organization health care provider has enumerated subparts, then it is required that the subpart’s NPI be reported as the Billing Provider.
  • The subpart reported as the Billing Provider must always represent the most detailed level of enumeration.
  • Must use the same organizational health care provider’s or subpart’s NPI for all the payers to whom you submit claims.
  • Review subpart enumeration schemas
  • If re-enumerating, communicate those changes to your business partners (payers, clearinghouses, trading partners, etc).
  • May require enrollment or system updates for your business partners in order for them to identify new or changed numbers for your organization.
  • Contact your business partners’ Enrollment Department for instructions on updating your NPI in their systems.
  • Update the National Plan and Provider Enumeration System (NPPES).
  • Service Facility NPI
  • NPI is not allowed within the Service Location for health care providers except when the Service Location is not part of the Billing Providers’ organization.
  • Must be an external entity to the Billing Provider identified in Loop 2010AA,* for example, an Independent Reference Laboratory.
  • Subparts with unique NPIs from the Billing Provider may no longer be sent in the Service Location and must be sent as the Billing Provider for the claim.
  • Loops 2310C and 2420C,* Data Element NM109
  • Rendering Provider NPI
  • If the Rendering Provider NPI represents an organizational provider, then it must be an entity external to the Billing Provider.
  • Individual NPIs will only be allowed to be sent as the billing NPI when services were performed by, and will be paid to, an independent, non-incorporated individual.
  • Loops 2310B and 2420A,* Data Element NM109

COB Balancing

  • COB data is required to balance the claim after adjudication by the Other Payer identified in Loop 2330B/2400.*
  • Remaining Patient Liability is a new AMT segment and is the remaining amount to be paid after adjudication by the Other Payer.
  • COB Payer Paid Amount is reported in an additional AMT segment.
  • Claim or Line Level Adjustments must be reported in the CAS segment to report prior payers’ claim level adjustments.
  • Amounts and Adjustments must balance to the total claim charge amount at both the claim and service line levels.
  • Loops 2320 and 2430,* Segments AMT and CAS

Admission Date

  • Required for all claims with inpatient medical visits and for all ambulance claims when the patient was known to be admitted to the hospital.
  • Must be on or before the Discharge Date.
  • Required when Place of Service is Inpatient 21, 31, 51, or 61.
  • Must not submit Admission Date on claims for which it is not required.
  • Loop 2300,* Data Element DTP03

Discharge Date

  • Required for inpatient claims when the patient is discharged.
  • Must be on or after the Admission Date.
  • Must not submit Discharge Date on claims for which it is not required.
  • Loop 2300,* Data Element DTP03

Anesthesia Services

  • Minutes are required for Anesthesia claims, units are no longer accepted.
  • Loop 2400,* Data Element SV103

Procedure Code

  • Must be sent with value of ‘HC’ Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes.
  • RelayHealth will reject claims that do not contain a value of ‘HC’.
  • Loop 2400,* Data Element SV101

Health Care Diagnosis Code

  • Must be sent with value of ‘BK’ ICD-9-CM until ICD-10-CM takes affect 10/01/2013.
  • RelayHealth will reject claims that do not contain a value of ‘BK’.
  • Loop 2300,* Data Element HI01-1

Drug Quantity

  • The CTP segment has changed from situational to required when Loop 2410, LIN03 National Drug Code (NDC) is present.
  • RelayHealth will reject claims that do not contain the Drug Quantity when NDC is present.
  • Loop 2410, Data Element CTP04