CMS Provides Guidance on 5010 Discretionary Enforcement Period for Medicare Fee for Service

Medicare Fee-for-Service (FFS) issued an announcement on December 14th regarding its plan for the 90 Day Discretionary Enforcement Period for non-compliant HIPAA covered entities.  According to that announcement, CMS provided a 90 day discretionary period for compliance with planned January 1, 2012 5010 transaction set requirements. However, it was unclear in that announcement whether CMS would continue to accept claims in the 4010 format during the discretionary period. In response to inquiries, CMS provided the following Q&A’s to spell out requirements that must be met in order to qualify for continued submission of 4010 claims between January 1st and March 31st.

 Medicare Fee for Service

1. Q: Will submitters who have not tested 5010 be able to continue to submit 4010 claims after January 1st while their transition plan is being reviewed by the MAC and if the plan is approved how much grace time will they be granted?

    A: Submitters who have not tested will need to submit their transition plan within 30 calendar days of the date of the notice from the MAC. Those who submit a transition plan by the deadline will have until April 1, 2012 to complete their transition to the 5010 formats.


2. Q: What will happen if submitters don’t submit a test plan? Will their 4010 claims be rejected as of the 31st day?

    A: If no transition plan is submitted Medicare FFS may direct the Medicare Administrative Contractors (MACs) to reject 4010 claims. The MACs have not been directed to reject 4010 claims at this time.


3. Q: Is Medicare going to release information about exactly what a compliance plan will look like?

    A: Medicare will not specify the format of the transition plan. Submitters should outline the steps they have taken and the steps they still need to take to successfully achieve compliance.


4. Q: Are the 30 day deadlines stated in the Medicare FFS announcement working or calendar days and does the 30 day clock start with notification or on January 1?

    A: The thirty day deadlines are calendar days and the 30 day clock starts with the date of the notification from the MAC.


5. Q: Will the MACs be able to accept a mix of 5010 and 4010 claims during the grace period?

    A: Yes, MACs will be able to accept a mix of 5010 and 4010 claims during the 90 day non-enforcement period.


6. Q: Who notifies providers that submit directly? What is the difference between a submitter and a provider?

    A: The MACs notify providers that submit directly. A submitter is a clearinghouse, vendor or biller that submits to Medicare on behalf of one or more providers. The Medicare 90 Day Discretionary Enforcement announcement requires submitters to test with their MACs, submitters to take action in regards to this plan and submitters to send it their transition plans. Medicare has developed the incremental steps in this plan to support the provider’s efforts in working with their submitters.

 Note: Although Medicare Fee-for-Service will accept 4010 claims during the 90 day discretionary period if the transition plans are submitted, other payers have announced plans to accept 5010 only and to reject all 4010 transactions. 


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