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5010 Frequently Asked Questions
This document provides answers to questions relating to ANSI 5010/NCPDP D.0. The document will be updated once information is forthcoming.
If you do not see your question listed, you can contact us for more information.
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What is the timeline for the DMMA Program upgrade to the HIPAA X12 5010 Transaction sets?
We expect Carriers and Vendors to be able to certify/test 837, 835 and D.0 transactions in the fall of 2011. Vendor testing will be performed for the remaining transactions prior to 1/1/2012.
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Will DMMA move to the new NCPDP version D.0 from the current NCPDP version 5.1?
Yes. Providers will continue to coordinate with their respective NCPDP carriers. Carriers and Chains will test directly with HP. Individual submitters will test/certify after the Carriers and Chains have completed their testing. The timeline for NCPDP certification is the Fall of 2011.
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How can I find out if my current communication software is compatible with 5010/D.0?
a. If you use software provided by a software vendor, billing service and/or clearinghouse, you should contact them as soon as possible to inquire about the 5010 version upgrade.
b. Recommended questions to ask:
i. Does your license agreement include "regulation updates"? The answer to this question will let you know from your vendor if the cost of upgrading to their version 5010 software will be an additional cost to you or whether the upgrade cost is already part of your license agreement.
ii. When can we expect to see software upgrades?
c. If you belong to an organization with an IT Department that has developed its own HIPAA compliant communication software, you should contact them as soon as possible to inquire about the 5010 version upgrade.
d. If you use the free Provider Electronic Solutions software provided by HP, updated 5010/NCPDP compliant software will be released.
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Do I have to recertify my HIPAA compliant software?
All covered entities who submit electronic transactions will be required to certify. This includes Software Vendors, Provider Groups, and Managed Care Organizations (MCO). If you submit your claims through one of these agencies, they will certify on your behalf. However, if you submit claims, you will need to recertify. If you submit your claims through a Managed Care organization (MCO), you should receive information from the Managed Care organization (MCO) with certification requirements. We will publish additional information at a future date concerning certification.
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I am a provider who submits claims through a Managed Care Organization (MCO) and Fee For Service (FFS). Do I need to certify for both methods?
If you are submitting claims FFS, please refer to question #4. If you also submit claims to any other entity, they should contact you with information on their certification requirements.
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I only submit claims through the Provider Electronic Solutions (PES) Software provided by HP free of charge. Do I need to recertify?
a. No. However, you will have to make sure you have downloaded the 5010 compliant version of Provider Electronic Solution (PES) before January 1, 2012.
b. Watch for additional information about these upgrades in a future DMAP Provider Bulletin or DMAP E-Mail notifications.
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I bill using paper claims. Does this affect me?
Currently there are no changes to paper forms, but there are some billing instruction changes. Effective 1/1/2012, only one NDC per JCode is allowed on a paper claim, the RX number can be billed as 12 digits, and units on Anesthesia Claims MUST be in minutes.
Due to the number of changes made to the transactions, CMS may publish updates to manual claim submission forms. If there are changes to these forms, the DMAP will communicate these updates to you through DMAP Provider Bulletins and E-Mail notifications.
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I am not a traditional healthcare provider, however I do submit claims for services. How will this affect me?
The HIPAA upgrade requires diagnosis codes to be entered on all 837 Professional claims. In the current 4010 model, diagnosis codes are situational; meaning exceptions are allowed based on DMAP policy. The 5010 837 Professional model does not allow for these exceptions. If you bill DMAP for services where a diagnosis code was not required under 4010, you MUST bill with a diagnosis code in 5010.
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Can I submit new ICD-10 codes once DE Medicaid implements the new version 5010 transactions?
No. Implementation of the ICD-10 is a separate project with a federal compliance date of 10/01/2013. Until business rules for ICD-10 codes are implemented on October 1st 2013, the DMAP will reject ICD-10 code set values if they are submitted on version 5010 claims.
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When will new 5010 Electronic Claims Submission (ECS) Guidelines be available for carriers and vendors to review?
Draft Versions of the ECS Guidelines for DMAP Electronic Claim submission and Payer Sheets for NCPDP Claims submissions are available at the http://www.DMAP.state.de.us website. As updates become necessary for each Guideline, the revision dates will be highlighted.
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How will we be informed of any updates or revisions to documentation for the 5010/D.0 Upgrade?
The website will continually be updated with new or revised documentation as well as updated FAQ's at http://www.DMAP.state.de.us. Monthly notifications of the 5010 Project progress will be available through DMAP E-Mail Notifications and Remittance Advice notifications on the DMAP ListServ. Also, a general update will be placed in each Quarterly Provider Bulletin through January 2012.
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What significant changes are known at present?
a. Coordination of Benefits reporting will be changing to collect additional coverage information from the primary payer at the level it is reported to DMAP.
b. Anesthesia Billing will be change to minute increments - instead of 15 minute intervals.
c. Prescription numbers will expand to 12 characters, and number of refills will now be collected.
d. Prescribing Provider First and Last name as well as Client and Card Holder first and last name data will now be required on NCPDP D.0 claims.
e. Service Facility provider will now be utilized on Institutional Claims, as defined by DMAP's policy.
f. Injectables and NDC's recorded on Encounters must now also include detail level COB segments reflecting the amount and date the Managed Care Organization paid the service.
g. On managed care organization encounter claims, the Managed Care Organization (MCO) paid amount will now be captured from the Other Subscriber Information and the Line Adjudication information loops where Other Payer data is reported.
h. On all 837 Professional claims, a diagnosis code must be entered.
i. Only one NDC per JCode is allowed on a paper claim, and the RX number can be billed as 12 digits
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Will new trading partner agreements, authorizations, enrollments, or identifiers be required before submitting 5010 test transactions?
No, there will not be new trading partner agreements, authorizations, enrollments or identifiers required before submitting 5010 test transactions.
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Will separate test files be required to each submitter ID maintained by the submitting entity?
Yes, separate test files will need to be sent for each transaction type. Certification will be by transaction type in 5010. Separate certifications will be required for each 837 transaction type as well as each of the response and 835 transaction sets.
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Will the receiving entity support parallel production 4010 and 5010 systems prior to January 1, 2012?
Yes. DMAP intends to allow Providers to voluntarily submit NCPDP D.0 and HIPAA 837 in the 5010 format in the Fall of 2011, prior to the mandated cutover date of 1/1/2012. The early timeframe will allow Providers to certify their transaction submission readiness for 1/1/2012. DMAP might allow Providers to cut over as early as November 2011.
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If so, will a separate submitter ID be required for 5010 transactions?
No, there will not be a separate submitter ID required for 5010 transactions.
Will a separate electronic communications connection be required for submission to the 5010 system?
No, there will not be a separate electronic communications connection required for submission to the 5010 system.
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How many test claims can be submitted per batch to the payer?
10-30 test claims can be submitted per batch. This number includes secondary Medicare and TPL claims.
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What is an acceptable pass rate?
The acceptable pass rate is 100%
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Will the trading partners research rejected transactions and then allow the submitter to re-test?
Yes, rejected claims will be researched and the submitter will be allowed to re- test.
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