Medical Billing: How to Troubleshoot Issues with the 5010 Platform

By Karen Smiley from Medical Billing and Coding For Dummies

As a medical billing professional, the transition to ICD-10 means working with and sometimes troubleshooting the 5010 platform. Experts have already identified problems associated with the 5010 transition, the primary one being that providers aren’t getting paid, or payments are vastly delayed. The transition has resulted in delayed claims processing and is causing the days in accounts receivable (AR) to grow.

The problem is that 5010 transmissions require electronic fields to populate differently than they did with the old platform, and some billing software systems aren’t uploading as expected. The result? Claims are stalling at the clearinghouse. When a claim is delayed at the clearinghouse, you usually have to manually fix the error until the correct software patch has been identified.

Here are some signs you can look for that indicate your provider’s 5010 claims have a problem:

You see an increase in rejections or claim denials. The problem may be that the billing software the provider uses isn’t sending the required information to the clearinghouse. Or it may be that the clearinghouse is not formatting the claim correctly before sending it on to the payer or intermediary. To get to the bottom of the problem as quickly as possible, give every rejection or denial top priority.
You’re no longer getting payments or explanation of benefits (EOBs) from payers who make payments via electronic fund transfers. The problem may be that the pay-to information isn’t transmitting correctly. Find out where the payment is and why; then find out how to fix it. Perhaps during 5010 transition, the payer incorrectly loaded the provider information, or maybe the information isn’t populating correctly on the outgoing claim.
Claims that used to automatically cross over (Medicare to secondary payers, for example) no longer cross. Check to make sure that payers such as Medicare who cross claims automatically to a secondary payer are receiving the secondary information on the claim. Some payers also cross over when the patient has a primary and secondary plan with the same payer.

If the automatic crossovers stop, call the primary payer and ask why the claim wasn’t sent. If they sent it, call the secondary payer and see whether the claim was received. If not, investigate and find out why. The likely culprit is a missing field on the claim, or the intermediary may have left it out during primary submission.
Primary claims show that they were sent by the billing software, but the clearinghouse doesn’t acknowledge receipt. Check and compare batch reports daily to make sure each claim sent is acknowledged. If the claims go missing at the clearinghouse, check with the software vendor to make sure that the file is being created and that you are sending the right file.

Some of the 5010 software systems create more than one batch, so you have to know which one to upload. The clearinghouse or software vendor should be able to help you identify which batch is the correctly formatted one.

The clearinghouse can fix some errors; for those the clearinghouse can’t fix, you must identify errors and then implement the fix on your end. Either way, the claim is delayed.

Other delays can occur at the payer, whose software must be 5010 ready as well. Most payers conduct 5010 readiness drills in preparation for these submissions, but depending upon provider and clearinghouse software, the claims are still not loading correctly and require manual intervention, which again causes delay.