CMS 5010 Delay

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On 11/17/11, CMS announced a 90 day delay in the enforcement of the ANSI 5010 claim standard on submitted claims on or after 1/1/12. The reason given was that with only 45 days left before the implementation of 5010 standards, it was determined that a majority of providers were still unable to comply with the new standards based on the current testing thresholds.

The Impact on the Industry

The impact of this announcement has created a “soft deadline” of 1/1/12 for the entire industry. In addition to CMS, we have not found any other payer that has plans to enforce the 1/1/12 deadline. In some cases, like Medi-Cal, the California Medicaid payer, even the new deadline of 3/31/12 will not be enforced. In fact, it is not known when Medi-Cal will even accept 5010 transactions.

This situation is similar to the implementation of 4010 which originally was to occur in 2001 and did not actually become mandatory for CMS until 10/2003 when the industry exceeded an 80% compliance rate. Instead of choosing a firm deadline for compliance, CMS seems to be waiting to see when the industry is becoming compliant at a certain level and then establishing the deadline. If this is true, there may be additional delays in the future. With CMS pushing these deadlines back arbitrarily, it will be difficult for 5010 to be enforced across the industry when CMS itself can set and then move its own deadline at its discretion.

Although this may seem to be a relief for providers in that it allows vendors additional time to prepare, it is going to generate new problems that may be more difficult to address than a firm 5010 deadline. Now, every provider will have a unique trading status with each payer or clearinghouse that they work with:

Current Phase

The payer requires 4010 transactions

Transition Phase

The payer accepts 5010 or 4010 transactions

Final Phase

The payer requires 5010 transactions

It appears that each of these provider to payer connections will transition from one phase to the next using a unique deadline associated with that connection and which may “float” based on compliance, payer readiness, or any other criteria deemed relevant by the payer.

Are You 5010 Ready?

Our 5010 Survival Guide will make sure you are on the right track.

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Many provider organizations, billing services, clearinghouses and other entities must deal with hundreds of these connections. Some of the vendor systems implemented do not allow for multiple formats for each connection or to transition from 4010 to 5010 independently on each one. The adoption of 5010 as an industry standard appears to be decaying as it becomes more of suggestion as to when it is implemented than a deadline. In any case, as an entity that must adapt to these standards to receive your revenue, make sure you have a plan for transition to 5010 that is connection oriented, not associated with a global deadline.

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