5010 Deadline Extended; Dual Eligible Problem Not Fixed

Acknowledging that many physicians and billing entities still aren't ready, federal officials are giving physicians three more months before it begins enforcing the use of Health Insurance Portability and Accountability (HIPAA) 5010 transaction standards. The new deadline is June 30.

The new transaction standards took effect Jan. 1, but the Centers for Medicare & Medicaid Services (CMS) gave physicians until March 31 to begin using them. On March 15, CMS issued a statement [PDF] that said it pushed back the deadline again because there still are problems with full implementation of the standards and it "believes that these remaining issues warrant an extension of enforcement discretion to ensure that all entities can complete the transition."

If you are already using the standards to file claims, fine. If not, continue preparing to start using them by June 30, or Medicare, Medicaid, and private insurers will reject your claims.

The TMA 5010 Resource Center includes background information on the issue; questions to ask vendors; contact information for electronic health record, practice management, and clearinghouse vendors; information on how you can finance upgrades to your existing system or purchase a new systems; and an action plan.

Check the TrailBlazer Health Enterprises and the Texas Medicaid & Healthcare Partnership (TMHP) websites to verify that your vendor is approved for Medicare and Medicaid 5010 claims. Contact your vendor as soon as possible if it is not on the list. TMA suggests contacting commercial carriers directly.

CMS said TrailBlazer Health Enterprises will continue working with clearinghouses, billing vendors, and health care professionals who need help submitting and receiving 5010 compliant transactions. Issues related to implementation problems with Medicaid may be emailed to Medicaid5010[at]cms[dot]hhs[dot]gov .   

Dual Eligible Medical Emergency Still Exists
The March 15 Action inadvertently gave the impression that state officials had resolved all of the problems that caused physicians not to be paid for treating patients eligible for both Medicare and Medicaid. Four issues were identified that caused Medicare Part B crossover claims to reject or deny incorrectly: 

  1. Some professional and outpatient hospital Medicare crossover claims may have received an incorrect reimbursement of $0 for the first detail line item on the claim. TMHP will reprocess incorrectly paid claims.
  2. Some anesthesia claims were denied incorrectly because of a change in how anesthesia minutes are reported in the HIPAA 5010 format. TMHP is developing a solution to systematically reprocess impacted claims.
  3. Claims may have been rejected incorrectly because Medicare-only information was transmitted to TMHP or information was not transmitted to TMHP in the appropriate format or location. TMHP is developing a solution to systematically reprocess impacted claims. 
  4. Crossover claims may be denied because of an invalid "performing provider." Performing physicians or other health care professionals not enrolled in the Medicaid program under the billing group TPI must complete an enrollment application. Once their enrollment is approved, the denied claims can be appealed. 

For complete details, read the full statement the Texas Medicaid & Healthcare Partnership posted on its website [PDF]. Remember, any claim that does not automatically crossover must be submitted manually.

The core problem remains. To save money because of a state budget crisis, the Texas Legislature last year ordered the Texas Health and Human Services Commission (HHSC) to pay no more than the Medicaid allowable for dual-eligible patients. Medicare will continue to pay its share of Part B services, but the policy change means Medicaid will not pay any additional amount for dual-eligible patients when Medicare's payment exceeds the Medicaid allowable for the same service. Several serious Medicare and Medicaid computer errors, some related to implementation of the 5010 standard, compounded the situation.

As a result, many physicians across the state face financial ruin, and their most vulnerable patients may lose their doctor. How bad is it? Watch this video about a family physician' practice in South Texas, or watch this one about a pair of Houston physicians..

TMA calls on state leaders to take emergency action to help for these patients, and the doctors who care for them. The state Legislative Budget Board (LBB) is the only entity that can mitigate or halt cuts when the legislature is not in session. Add your name to the "Medical Emergency Petition" today. Share it with your colleagues, friends, and family. Help the Hidalgo-Starr County Medical Society collect a thousand-plus signatures by March 27 for its "House Call" town hall meeting in McAllen. Texas legislators and HHSC are invited. Help us demonstrate how the state cuts to dual-eligible patients affect your patients and your practice.

Caution: Asking patients to sign the petition in your waiting and/or exam rooms or using your patient contact information to solicit petition signatures is not advised. HIPAA restricts such use without first obtaining HIPAA-compliant patient authorization.

Action Special Issue, March 19, 2012 

Last Updated On

July 25, 2023

Originally Published On

March 19, 2012