HIPAA 5010: Who’s Exempt?

Q. I have a small practice in a small town. Adopting HIPAA 5010 electronic standards by Jan. 1, 2012, is a huge hurdle for me — almost insurmountable. Is there a way I can get out of this requirement?

A. If you file claims electronically, you must use the 5010 standards starting Jan. 1, 2012. No payer will accept claims under the 4010 standards starting on that date.

Do you have to file claims electronically? If you file Medicare claims, the answer is yes — unless your practice has fewer than 10 employees (full-time equivalent) or submits fewer than 10 Medicare claims per month on average during a calendar year. If either exemption applies, you are allowed to file paper claims. TrailBlazer will follow up with a Request for Documentation letter, to which you must respond, demonstrating your eligibility to submit paper claims, within 45 days of receipt. See the Medicare Claims Submission (PDF) manual for details about eligibility.

If you file claims only with private payers, you still may be required to file electronically. Check your contract with each payer. If the contract does require electronic submission, state law (TAC §21.3701) exempts practices with fewer than 10 employees (TMA made sure of that). You have to apply to the private carriers individually for a waiver.

If you fall under one of these exemptions but already do electronic billing, can you switch back to paper to avoid an expensive 5010 upgrade? It’s not that simple. That’s because your current credentials and contracts are set for electronic transactions. To drop to paper, you will need to change your status with all of your payers; this is a huge undertaking. Moreover, you can expect a three-fold increase in the length of time to get paid.

Go to the TMA HIPAA 5010 Resource Center for help and information regarding the upgrade to 5010.

Published Oct. 10, 2011

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