Medicare Compliance & Reimbursement

You'll want to start double- and triple-checking your claim forms to ensure that the beneficiary's information is spot-on, or you'll face scores of denied claims once CMS starts requiring the new HIPAA 5010 forms.

That's because CMS plans to deny claims filed on HIPAA 5010 forms (which will be the new Medicare universal claim form starting in 2012) on which the beneficiary's name doesn't perfectly match how it's listed on his Medicare I.D. card.

"Whenever there is a name suffix, such as 'Jr.' or 'Sr.' abbreviations, etc., it must be included with the last  name," said Veronica Harshman of CMS's Division of Medicare Billing Procedures during an April 28 Open  Door Forum regarding the eligibility component of the HIPAA 5010 form.

You can include the suffix either with the patient's last name or in the suffix field, specified CMS's Chris Stahlecker during the call.

"The date of birth must also match exactly to what the SSA (Social Security Administration) has on file," Harshman said. CMS will use several new error codes on claims once the 5010 form goes into effect. "If you communicate with CMS through a third-party vendor, it is strongly recommended that you discuss with them how these errors will be communicated to you and how these changes will impact you and your business," Harshman advised.

According to the HIPAA 5010 Final Rule, CMS will have a production 5010 system available as of Jan. 1, 2011, Harshman said.

The last day CMS will accept a 4010A1 form will be Dec. 31, 2011. As of Jan. 1, 2012, if you aren't using the 5010 form, you'll "lose the ability to receive eligibility data from Medicare," Harshman said. In other words, she noted, mandatory compliance of the 5010 form will begin on Jan. 1, 2012.

Contact your software vendors soon to determine when you can expect your software to be upgraded so it's 5010 ready, Harshman said.

Plus: "Don't forget many of your business processes which may also need to be changed," she noted. For instance, you may want to evaluate how the new form will impact patient registration, billing, appointment scheduling, claims reconciliation, etc., Harshman noted.

Resource: CMS developed several educational products that can help with your 5010 transition, including a  side-by-side comparison of the current 4010 form versus the new 5010 form. Visit www.cms.gov/versions5010andD0for more information.