Ansi 5010

Whitepaper

ANSI 5010: What You Need to
Know to Manage the Change
athenahealth, Inc.
Published: April 2011

ANSI 5010: What You Need to Know to Manage the Change

Executive Summary
Achieving ANSI 5010 compliance is the first step on the road to the October 1, 2013, transition to ICD-10-
compliant health care claims systems. The deadline for physician practices to achieve ANSI 5010 compliance—
and avoid a breakdown in claims payment and possibly federal fines—is less than a year away. However, many
practices are a long way from achieving this compliance, and some don’t even have a plan for getting there.

The most recent HIMSS survey of progress toward ANSI 5010 compliance found that the five major obstacles
to its achievement are: (1) some practices are busy with EHR implementation and meaningful use; (2) practices
face competition for scarce technical resources; (3) some payer systems aren’t ready; (4) some vendor
systems aren’t ready; and (5) some clearinghouse systems aren’t ready.1

Considering the fact that four of these obstacles are beyond the direct control of physician practices, what
are you to do? It’s nearly impossible to overcome these obstacles on your own, but the cost of getting help
can be prohibitive as well. It has been estimated that the average practice will spend $285,000 transitioning
to ICD-10, and achieving ANSI 5010 compliance will be a significant component of that cost.2 But the cost of
your system not being compliant, or not being unable to cope with noncompliant payers, is also steep. One
organization has even suggested that practices take out a line of credit to see them through this transition
period, when payments could be delayed for long periods of time!3

The solution is to work with a billing and practice management service that will not only guide you toward
ANSI 5010 (and ultimately ICD-10) compliance, but will also make your billing and practice management
system compliant and take on the burden of overcoming obstacles—without charging additional fees.
Achieving compliance requires a complex set of considerations and tasks—including coordinated testing
with all of your payers and clearinghouses—both before and after ANSI 5010 becomes the industry standard.
The considerations and tasks outlined in this whitepaper can help ensure that you cover all of the bases for
achieving ANSI 5010 compliance yourself and coping with vendors who are late complying.

www.athenahealth.com 3


ANSI 5010: “You can’t sit back and wait”
By January 1, 2012, the healthcare industry will have completed the migration from the current ANSI 4010
electronic claims transaction format standard to the ANSI X12 version 5010 standard. ANSI 5010 is a federally-
required update to the current electronic transaction standard implemented under HIPAA and an important
prerequisite for the ICD-10 conversion required on October 1, 2013. Since the ANSI 4010 format does not
support the number or length of codes required by ICD-10, “it’s absolutely essential that the 5010 platform be
stable before the ICD-10 conversion,” says Joel Slackman, managing director for policy at the Blue Cross and
Blue Shield Association. 4

The federal Centers for Medicare and Medicaid Services (CMS) has stated that, “The industry will realize
many benefits with the implementation of Version 5010 in addition to those from implementation of ICD-10.
One example of Version 5010 benefits is decreased staff time required for activities such as manual lookup
of information and phone calls to insurance companies to verify eligibility, claims denials, and appeals.”5 The
Department of Health and Human Services estimates that the net financial benefits to the healthcare industry
for implementing ANSI 5010 could be as high as $38.8 billion.6 These long-term benefits come at the price of
short-term costs, however. Gartner Research estimates that the industry-wide cost of implementing ANSI 5010
will be somewhere between $5.5 billion and $11 billion.

All healthcare industry transaction connections must be tested and converted to ANSI 5010 no later than
December 31, 2011, and practices must be able to operate in production mode with the new version of the
standard.

ANSI 5010 changes all standard electronic transactions, including:

• Health Care Claims (837P & 837I)
• Eligibility (270/271)
• Health Claim Status (276/277)
• Health Care Remittance Advice (835)
• Healthcare Services Review (278)
• Acknowledgement (999-new)

If you’re hoping these changes will not be disruptive, consider the complications that arose during the
transitions to HIPAA and NPI. ANSI 5010 updates may “break” payer systems, which could cause problems as
big as, or bigger than, those caused by HIPAA and NPI. HIMSS warns that “When [5010 is] not implemented
properly, the organization’s financial and clinical integrity is threatened.”7

There is no guarantee that the timing of the changeover to ANSI 5010 will go smoothly, either, which could
cause additional headaches for providers. Erroneous denials on 4010 claims due to ANSI 5010 system changes
are already appearing and having unintended negative effects. At the 2011 HIMSS annual conference, a CMS
presentation indicated that five state Medicaid agencies will not be ready for the ANSI 5010 transition on time
and two will convert inbound 5010 transactions to their 4010 equivalents for processing.8 And an industry
panel at the same conference revealed that providers may be forced to support both the original 5010 Final
Rule and later mandated Errata 5010 versions for some time, just as they did with 4010 and 4010A1.9 The 5010
versions will need to be supported in addition to the 4010 payers who have not yet been converted.10

4 www.athenahealth.com


The Workgroup for Electronic Data Interchange (WEDI) recommends that practices “should prepare for the
‘what if’ scenario of disruptions in the processing of claims transactions” by taking actions such as decreasing
expenditures leading up to the ANSI 5010 transition, establishing emergency procedures to handle any urgent
corrections needed to practice management and billing systems, and even establishing a line of credit with a
financial institution to cover delays in claims payment.11

Clearly, the possible complications of this transition should not be taken lightly. But despite the gravity of the
situation, many practices are not acting with sufficient urgency. Health care information technology writer Neil
Versel says, “When the HIPAA transaction standards first took effect with Version 4010, people mistakenly
assumed the vendors would take care of everything.”12 Stanley Nachimson, who serves on the 5010 Task
Group of the Workgroup for Electronic Data Interchange (WEDI), seconds Versel: “You can’t sit back and
wait.”13

What are the obstacles to ANSI 5010 compliance?
The most recent HIMSS survey of progress toward ANSI 5010 compliance14 found that the five major obstacles
to its achievement are:

1. Some practices are busy with EHR implementation and meaningful use.
2. Practices face competition for scarce technical resources.
3. Some payer systems aren’t ready.
4. Some vendor systems aren’t ready.
5. Some clearinghouse systems aren’t ready.

Obstacle 1 is not directly relevant to ANSI 5010 compliance, and obstacles 2–5 are not within the direct
control of an individual practice, so what can you do? First, you can recognize that going it alone is not only
going to be more difficult, but in the end more expensive—both to achieve the implementation with all of
your payers and clearinghouses and to deal with the fallout if problems arise with the processing of claims
post-implementation. It is important to know that someone is “watching your back.” That someone should be
intimately familiar with electronic claims submission—ideally your billing and practice management vendor.

It has been estimated that the average practice will spend $285,000 transitioning to ICD-10,15 and achieving
ANSI 5010 compliance will be a significant component of that cost. However, your billing and practice
management vendor ought to be on top of the situation, already well along in working with payers and
clearinghouses to plan for the transition, and able to integrate ANSI 5010 changes into your system with little
effort by, or cost to, your practice. HIMSS recommends that any billing and practice management system
you work with be “either 5010 compliant or the vendor has a rock-solid plan for achieving Version 5010
compliance and guarantees this as part of any new contract at no additional cost.”16 Some vendors will claim
that ANSI 5010 and ICD-10 changes to your system will not cost your practice anything “additional,” but they
may fold the cost of those changes into an upgrade that contains other changes, disguising the fact that you
are actually paying for them. In addition, an upgrade that makes it impossible to revert to Version 4010 with
payers who are addressing Version 5010 problems could lead to additional processing headaches and loss of
revenue.



What should your vendor do for you?
The tasks that need to be performed in order to ensure your practice’s successful transition to ANSI 5010 are
as follows:

1. Review and interpret ANSI 5010 requirements.
2. Update your billing and practice management system to reflect ANSI 5010 transaction standard.
3. Clarify when each of your payers and clearinghouses will be ready to accept ANSI 5010 transactions and
plan for the transition with each of them.
4. Test the performance of your system with each payer and each type of new transaction before ANSI 5010
goes live.
5. Monitor your transactions after ANSI 5010 goes live to ensure that they are cycling properly.
6. Monitor your claims to ensure that you’re still being paid adequately and in a timely manner.

As you can see, the list is daunting. Assuming that you have, or will contract with, a vendor to handle your
5010 transition, let’s examine each of these tasks to determine what that vendor can do to make the process
as painless as possible for you.

1. Review and interpret ANSI 5010 requirements.
In order to make changes that meet ANSI 5010 requirements, you must understand those requirements—
documented in more than 2,500 pages of implementation guides—and understand how each payer will
interpret them. For example, the practice address used for credentialing purposes will now be required on all
claims, but it’s not clear which address each payer will want—physical, billing, or even corporate (for larger
practices)? Not getting this right may delay claims payment, so your address must be validated in advance for
each payer who plans to utilize the new address in provider matching.

Similarly, some payers will now require both the insurance policyholder’s ID and the treated patient’s ID—
even when the treated patient has a unique ID—while others will only want that of the policyholder, and still
others will only want the patient’s ID. This means that construction of the eligibility transaction, which is
already complex in 4010 and critical to claim payment, becomes even more nuanced and integral to successful
claim processing after 5010 implementation. There are also services that only a small minority of practices use
which must be documented (e.g., special data fields required for minutes capture for anesthesia services) in
order for some claims to be processed successfully. Because these services are used by so few practices, they
can be easily neglected in the transition to ANSI 5010, causing problems later on.

What your vendor should do:
• Confirm the address required by each of your payers and clearinghouses and validate content as
appropriate if a payer will be using the address for provider or contract identification.
• Confirm the patient ID format required by of each of your payers and clearinghouses for eligibility
transactions.
• Confirm all other new or different data required by each of your payers and clearinghouses
• Confirm the need for, and nature of, any special data fields required for special services with each of
your payers and clearinghouses.



2. pdate your billing and practice management system to reflect
U
ANSI 5010 transaction standard.
Your billing and practice management system will need to be updated to accept the new ANSI 5010 data
requirements. For software that is not cloud-based, this means an upgrade—and, more than likely,
multiple patches over time. However, as indicated earlier, the transition to ANSI 5010 is unlikely to happen
across the board by the current deadline, so you may need to operate with multiple versions of ANSI 5010
simultaneously, as well as having the capacity to submit claims in ANSI 4010 format for payers who are not on
schedule. This could be a massive headache and expense for providers, and how your vendor manages these
complexities could determine how your practice weathers the transition to ANSI 5010.

• Update your system to capture both subscriber and patient ID and automatically format transactions
with the appropriate ID(s) for each of your payers and clearinghouses.
• Update your system to capture all new or different data required by each of your payers and
clearinghouses.
• Update your system to capture any special data required for special services by each of your payers and
clearinghouses.

3. larify when each of your payers and clearinghouses will be ready to
C
accept ANSI 5010 transactions and plan for the transition with each of
them.
It would be convenient if all of your payers and clearinghouses were ready to accept ANSI 5010 transactions
for testing at the same time (and if that date was the CMS recommended January 1, 2011). But, in all likelihood,
they will vary from early readiness to not being ready to accept all new transactions until after the ANSI 5010
compliance deadline required by the federal Department of Health and Human Services (HHS). This means,
for example, that you may need to submit to some payers a combination of 4010 and 5010 data (e.g., claims
in 5010, eligibility in 4010). Working with payers and clearinghouses to keep them on schedule for ANSI 5010
transaction readiness, finding out when they’re ready, and planning for the transition will require constant
vigilance. If you have more than a few payers and clearinghouses, this is a highly demanding job.

• Work with the help desks of each of your payers and clearinghouses to establish when they will be
ready to accept each of the following updated ANSI 5010 transactions:
−− Claims
−− ERA
−− Claim Status Inquiry
−− Eligibility
• Work with the help desks of each of your payers and clearinghouses to plan when and how readiness
will be tested.
• Establish a schedule for both pre-live and production level testing of each new transaction.



4. est the performance of your system with each payer and each type of
T
new transaction before ANSI 5010 goes live.
When your vendors and clearinghouses claim to be ready to accept new ANSI 5010 transactions from your
system—that readiness must be fully tested. Ideally, this testing should have begun already. And, as vendors
and clearinghouses may phase in different transactions at different times, you need to provide test claims for
each new transaction as your payers and clearinghouses make them available.

• Manage testing and roll-out calendars for each new transaction with each of your payers and
clearinghouses.
• Work with the help desks of each of your payers and clearinghouses to resolve any transaction
processing problems that arise during testing.
• Ensure that any special services offered by your practice are being properly documented within the
system and are being accepted by each of your payers and clearinghouses.

5. Monitor your transactions after ANSI 5010 goes live to ensure that they

are cycling properly.
As the saying goes, the proof is in the pudding. It will be impossible to determine the ultimate success of your
practice’s and the industry’s transition to the ANSI 5010 standard until the final cutover happens,and all payer
and clearinghouse systems are operating with a full load of claims from all of their providers. In addition,
there will be payers and clearinghouses that have made only a partial transition to ANSI 5010, which has
the potential to cause all kinds of headaches for practices. You will need to carefully monitor transactions to
ensure that your claims are going through.

• Confirm that each new transaction is processing successfully (e.g., that the patient IDs being sent are
being accepted and processing normally) or that changes are needed to format/values—and make those
format/values change within your system on an ongoing basis.
• Establish with each of your payers and clearinghouses workarounds for ANSI 5010 transactions that
don’t process correctly (e.g., your vendor immediately resubmits them as 4010 transactions, until 5010
transactions are functioning properly).
• Monitor claims issues affecting all practices on the same billing and practice management system to
ensure that issues affecting one aren’t affecting others.
• Monitor claims to ensure that rejections for any reason (e.g., NPI issues) by any of your payers and
clearinghouses are not tied to system changes made for ANSI 5010 compliance—even if the issues seem
on the surface not to be connected to ANSI 5010 changes.
• Monitor payments for any special services offered by your practice to ensure that they are being
properly processed by each of your payers and clearinghouses.



6. onitor your claims to ensure that you’re still being paid adequately and
M
in a timely manner.
It’s obvious that a major system change such as that involving ANSI 5010 could affect the timely processing
of claims—and that issue must be monitored with vigilance. However, it is less obvious that ANSI 5010
transaction changes could also lead to payment adequacy problems. ANSI 5010 changes could affect the
matching of claims with the correct rate for a procedure as negotiated in your practice’s contract, which could
lead to your being paid less than you deserve. It will be important to track both the timeliness and adequacy
of your claims payments after the ANSI 5010 transition.

• Monitor the timeliness of claim payments by each of your payers and clearinghouses to ensure
that ANSI 5010 transactions are not slowing down payments. This is particularly important with
clearinghouses; if they hold up a claim due to ANSI 5010 errors, your payer will consider your claim as
not having been submitted at all, and you may not realize for 30-50 days that the claim is not being
processed!
• Monitor the adequacy of payments by each of your payers and clearinghouses to ensure that, if
payments are lower than expected, it is not due to errors introduced by ANSI 5010 transaction changes.

How to recognize, and measure, a successful ANSI 5010 transition
Yogi Berra had it wrong—when it comes to the transition to the ANSI 5010 standard, it ain’t over even when it’s
over. Only by monitoring key metrics over time after the transition is complete will you ensure that your claims
are being submitted and processed successfully under the new standard. Those key metrics are:

1. First-Pass Resolution Rate – Percentage of claims being accepted for processing without the payer
coming back to you for more or different data
2. Days in Accounts Receivable – Average number of days it takes a payer to process your claims
3. Front End Rejection Rate – Percentage of your claims rejected by clearinghouses or payers due to
inadequate or erroneous data without making it into the payer’s adjudication system
4. Denial Rate – Overall percentage of your claims that are being denied
5. EDI Rate – Percentage of your claims that are being submitted electronically, rather than via paper
6. Hold Rate – Percentage of your claims being held up within your billing system because of inadequate
or erroneous information
7. Manual Posting Rate – Percentage of your claims you need to post manually due to problems with the
electronic files
8. Eligibility Patient Not Found Rate – Percentage of your eligibility transactions where the patient was not
uniquely identified in the payer’s system, preventing insurance validation and increasing the likelihood
of front end rejections and denials
9. Payment Adequacy – Your success at getting claims paid at the appropriate level

Your billing and practice management vendor should not only be able to deliver statistics on all of these
metrics to you regularly, but should also be capable of helping you interpret those statistics in the light of
ANSI 5010 changes—and capable of suggesting what can be done to improve them.



There is a better way to manage the ANSI 5010 transition in a smooth and non-disruptive way. Your billing
and practice management vendor should be a partner in the transition to ANSI 5010, not just a supplier of
software. Your vendor should be ready to handle the transition well in advance, and they should leverage
their relationships with payers and clearinghouses to ensure that they, too, are ready—or that they will be
able to provide reasonable workarounds. Your vendor should not only ensure that your system will transition
seamlessly to ANSI 5010, but should also relieve you of the pain and expense of making that transition.

athenahealth: Timely ANSI 5010 Compliance—At No Cost to You
athenahealth has been working hard for a long time to prepare for the ANSI 5010 conversion—leading
the industry with early Level I compliance, conducting research to discern what changes payers and
clearinghouses will be making, and testing with them. Our patented billing rules engine is continuously
updated—at no additional cost to our clients—and will continue to be updated throughout the transition to
ANSI 5010. Other steps we have taken include:

• Putting procedures in place to ensure minimal disruption of service and cash flow for practices
• Working with payers and clearinghouses to establish readiness timelines, testing scenarios, and
specific changes for ANSI 5010 implementation.
• Participating in industry ANSI 5010 events and proactively contacting industry stakeholders to
determine readiness timelines.
• Continually making application and operations changes to support ANSI 5010.
• Creating new and updated fields in patient and billing workflows to ensure compliance.
• Updating the 1,000 claim formatting rules to support ANSI 5010 requirements.
• Testing with payers and clearinghouses well in advance of the January 1, 2012 transition date. In
addition to pre-live testing, we will send small production batches of claims in ANSI 5010 format prior
to migrating a payer to ANSI 5010. We are the first test partner with several of our direct connection
payers, and we will likely be among the first to bring ANSI 5010 transactions live.

We will closely monitor the results of all testing—and your claims performance on an ongoing basis—in order
to minimize the financial and procedural impact of ANSI 5010 on your practice.

l learn more about athenahealth’s cloud-based services, visit
To
athenahealth.com or call 866.817.5738.



Citations
1. Neil Versel, 5010: Transitioning to the New Standards, For The Record, Apr. 27, 2009, p. 14.

2. New Study Finds ICD-10 Mandate Hardship for Health Care Providers, MGMA Press Room, Oct. 14, 2008,
http://www.mgma.com/press/article.aspx?id=22612.

3. 5010 837 Issue Brief: Strategizes to Minimize Impacts of Potential Claims Disruptions. Workgroup for
Electronic Data Interchange 2011, p, 4.

4. Versel, supra, p. 14.

5. HIPAA Transaction Code Set 5010: Implications and Opportunities. Healthcare Information and
Management Systems Society 2009, p. 4.

6. Health Insurance Reform: Modifications to the Health Insurance Portability and Accountability Act (HIPAA)
Electronic Transaction Standards. Federal Register. Vol. 73, No. 164, Friday, Aug. 22, 2008.

7. HIPAA Transaction Code Set 5010: Implications and Opportunities, p. 11.

8. State of the 5010 World, Centers for Medicare and Medicaid Services Office of Information Services,
(February 21, 2011) Healthcare Information and Management Systems Society.

9. Who’s Ready? Industry Panel on 5010 Readiness. Healthcare Information and Management Systems
Society 2010.

10. Ibid.

11. 5010 837 Issue Brief, supra, p. 4.

12. Versel, supra, p. 14.

13. Versel, p. 14.

14. HIMSS ICD-105010 Industry Readiness Survey: Progress on 5010 but Challenges Ahead, January 2011,
http://www.mbproject.org/documents/MicrosoftWord-ProviderReadinessSurveyDecember2010final..pdf.

15. New Study, supra.

16. HIPAA Transaction Code Set 5010: supra, p. 13.


© 2011 athenahealth, Inc. All rights reserved.

About athenahealth At athenahealth we offer the leading cloud-
based practice management, EHR, and patient communication services
that help medical groups get more money and more control of patient
athenahealth, Inc.
311 Arsenal Street care. To learn how our services can help your organization, contact us at
Watertown, MA 02472 866.817.5738 or www.athenahealth.com.
866.817.5738

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