CMS extends 5010 enforcement discretion through June 30

April 30, 2012

The Centers for Medicare & Medicaid Services (CMS) Office of E-Health Standards and Services (OESS) announced March 15, 2012, it will not initiate enforcement action for an additional three months, through June 30, 2012, against health care practitioners, institutions, or product suppliers who have not implemented ASC X12 Version 5010 and NCPDP Versions D.0 and 3.0 software.

The software is required to comply with the updated transactions standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The CMS had most recently planned to begin enforcing the 5010 software requirement on March 31, 2012.

HIPAA called for 5010 implementation by Jan. 1, 2012. However, on Nov. 17, 2011, the OESS announced that, for a 90-day period, it would not initiate enforcement action against any covered entity that was not compliant with the updated versions of the standards by the New Year’s Day compliance date.
This was referred to as enforcement discretion, and during this period covered entities were encouraged to complete outstanding implementation activities including software installation, testing and training.

“Health plans, clearinghouses, providers and software vendors have been making steady progress: the Medicare Fee-for-Service (FFS) program is currently reporting successful receipt and processing of over 70 percent of all Part A claims and over 90 percent of all Part B claims in the Version 5010 format. Commercial plans are reporting similar numbers. State Medicaid agencies are showing progress as well, and some have made a full transition to Version 5010,” CMS officials said in announcing the extension last month.

“Covered entities are making similar progress with Version D.0. At the same time, OESS is aware that there are still a number of outstanding issues and challenges impeding full implementation,” the CMS said.

The OESS believes that these remaining issues warrant an extension of enforcement discretion to ensure that all entities can complete the transition.

The OESS expects that transition statistics will reach 98 percent industry wide by the end of the enforcement discretion period, the CMS statement continued.

Given that the OESS will not initiate enforcement actions through June 30, 2012, industry is urged to collaborate more closely on appropriate strategies to resolve remaining problems, officials said. The OESS is stepping up its existing outreach to include more technical assistance for covered entities.

The OESS is also partnering with several industry groups as well as Medicare FFS and Medicaid to expand technical assistance opportunities and eliminate remaining barriers. Details will be provided in a separate communication.

The Medicare FFS program will continue to host separate provider calls to address outstanding issues related to Medicare programs and systems.

Medicare Administrative Contractors (MACs) will continue to work closely with clearinghouses, billing vendors or health care providers requiring assistance in submitting and receiving Version 5010 compliant transactions. Any entity is experiencing difficulty reaching a MAC can send a message describing the problem to Provider Feedback@cms.hhs.gov with “5010 Extension” in the subject line.

The Medicaid program staff at the CMS will continue to work with individual states regarding their program readiness. Issues related to implementation problems with the states may be sent to Medicaid5010@cms.hhs.gov.

“OESS strongly encourages industry to come together in a collaborative, unified way to identify and resolve all outstanding issues that are impacting full compliance, and looks forward to seeing extensive engagement in the technical assistance initiative to be launched over the next few weeks,” the CMS statement continued.

AOA members can access additional information including a link to the CMS ICD-10 website and a CMS 5010 implementation widget on the AOA 5010 webpage (www.aoa.org/5010).

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