Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth All Provider Bulletin 210 May 2011 TO: All Providers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: 5010 Implementation Preparation Background The Centers for Medicare & Medicaid Services (CMS) has mandated that on January 1, 2012, the standards for electronic health care transactions must change from version 4010/4010A1 to version 5010. MassHealth is actively working toward this January 1, 2012, implementation date. All electronic health care transactions currently submitted to, or returned from, MassHealth in the 4010A1 version are affected. Please see All Provider Bulletin 205 for a list of the transactions impacted. 5010 Preparation your organization? Are you actively preparing for 5010 implementation? Has 5010 been discussed within It is important that you are aware of how 5010 will impact your organization. MassHealth will continue to provide information to educate its trading partners on this very important federal mandate. To ensure a smooth transition from 4010/4010A to version 5010 within your organization, please be sure to do the following. * Discuss MassHealth’s 5010 implementation within your organization, using the information in this bulletin, and the other related materials posted at www.mass.gov/masshealth/5010. This material provides an overview of 5010, outlines the key changes to the transactions, and communicates key timelines. * Have an implementation plan in place that addresses the key changes required to meet the January 1, 2012, implementation date, and confirm that your organization is on target to meet the deadline. * Monitor MassHealth activities and requirements via the MassHealth 5010 Web site to ensure a successful implementation. * Use the testing readiness materials such as companion guides, billing instructions, and special instructions, if your organization will be testing directly with MassHealth. You should also know the testing timelines and ensure that you are ready to test. * Inquire about software updates and testing timeline, if your organization is using a software vendor. Know your vendors’ readiness plans to ensure they are ready for the January 1, 2012, implementation. (continued on next page) 5010 Preparation (cont.) As previously noted, MassHealth will not support the submission of 5010 production files before the implementation date of January 1, 2012. Additionally, MassHealth will not accept any 4010 transactions after December, 31, 2011. If you, your billing intermediary, and/or software vendor have not successfully tested with MassHealth before January 1, 2012, this will impact your ability to successfully adjudicate claims and receive payment. Coordination of Benefits (COB) Does your organization support coordination of benefits (COB) claims? If yes, did you know that MassHealth supports the following? * 837P and 837I COB * direct data entry of COB through the POSC If you are interested in testing 837P COB or 837I COB with MassHealth, please specify this when you schedule your 5010 trading partner testing, or contact EDI@mahealth.net. Paper Reduction The transition to 5010 is an opportunity for those trading partners and providers who currently submit paper claims to change their business process and submit claims electronically. As part of the 5010 implementation, MassHealth will be making some additional changes to eliminate the need to send any claims by paper. These changes include modifying the POSC to allow providers to enter NDC data, as well as submit 90-day waiver claims electronically. More details about paper reduction will be outlined in future bulletins. Web Page In an effort to keep providers informed, MassHealth has developed a 5010 Web site at www.mass.gov/masshealth/5010. This Web site contains general information about 5010, training and educational materials, billing instructions, companion guides, and other relevant information necessary to aid providers with the successful implementation of 5010 with MassHealth. It is important that you bookmark this site as it will be updated frequently to reflect the status of vendor testing with MassHealth, and other business requirements that will need to be followed to ensure claims submissions will not be impacted at your facility. Companion Guides Draft versions of the 5010 companion guides were issued in April and May 2011. Please note that while this is the first iteration of the companion guides, MassHealth strongly recommends that trading partners use this version to modify their systems to support 5010 transactions. The following companion guides will be issued. April 2011 May 2011 June 2011 270/271 834 Inbound 276/277 835 834 Outbound 820 837I and COB 837P and COB (continued on next page) Testing MassHealth will conduct testing with active submitters (those who have submitted transactions within the past year) before the 5010 implementation date. MassHealth will conduct testing in three phases. Testing Phase Who Is Involved in What Is Being Time This Testing Phase? Tested? Period Beta Limited number of * Batch transactions July – Aug. 2011 select submitters * Direct data entry that represent a * Paper claims cross-section of the MassHealth submitter population Vendor All software vendors, Batch transactions Sept. – Oct. 2011 clearing houses, and commercial billing intermediaries Trading All other trading Batch transactions Oct. – Dec. 2011 Partner partners MassHealth requires trading partners to test HIPAA transactions before submission into production. In order to ease the burden of 5010 testing, MassHealth will test only with those entities that truly require testing. Providers who use a billing intermediary that has successfully tested with MassHealth are not required to test with MassHealth for those transactions that the billing intermediary currently supports. Providers who use a software vendor should confirm that their software vendor has successfully tested with MassHealth before submitting test claims for consideration. Please note that MassHealth’s priority is to ensure that all the mandatory transactions are successfully tested. Additionally, since there are limited changes being made to the eligibility (270/271) and claims status (276/277) transactions, trading partners are not required to test these transactions. Some providers may want to submit these transactions to ensure that their transaction can be accepted and processed by MassHealth. Providers who submit claims through a billing intermediary that has successfully tested transactions with MassHealth will not be required to test that specific transaction during trading partner testing. These transactions will be considered optional. MassHealth will test the errata version of the transactions only. The 835 and TA/999 transactions will be generated as applicable, and sent to the appropriate trading partner during testing. The table below outlines which transactions are mandatory and which ones are optional for providers and vendors to test, before the 5010 implementation date. Transaction Description Provider Vendor 270/271 Health-care benefit inquiry Optional Mandatory and information response 276/277 Claims status inquiry and Optional Mandatory response 820 Health-care premium payment Mandatory N/A 834 Inbound 834 benefit enrollment Mandatory N/A and maintenance 837P Health-care claim: professional Mandatory Mandatory 837I Health-care claim: institutional Mandatory Mandatory (continued on next page) Testing (cont.) Please note that upon scheduling your test, MassHealth EDI staff will work with you to determine which transactions are considered mandatory to test and which transactions are optional. Each submitter and provider should test transactions that represent the typical type of electronic transactions that they currently exchange with MassHealth. Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to EDI@mahealth.net, or fax your inquiry to 617-988-8974.