Home Health & Hospice

CMS Responds to Questions Regarding 5010 Enforcement

Homecare Insider, January 9, 2012

Several issues related to the Centers for Medicare and Medicaid Services’ (CMS) plan for the 90-day 5010 discretionary enforcement period for non-compliant HIPAA covered entities were clarified in its recent response to frequently asked questions.

CMS stated that submitters who haven’t tested should have submitted their transition plan by January 1, 2012 and will have until April 1, 2012 to complete their transition. If no transition plan is submitted, CMS may direct Medicare Administrative Contractors (MAC) to reject claims submitted in the 4010 format.

CMS also said that they are not requiring a specific format for the transition plan, however it should outline the steps taken and the steps they still need to accomplish to successfully achieve compliance. The 30-day deadlines in the Medicare Fee-for-Service announcement are calendar days and start with the date of the notification from the MAC. MACs will be able to accept a mix of 5010 and 4010 claims during the 90-day non-enforcement period. 

Finally, when asked about notification of providers who submit claims directly and what the difference is between a submitter and a provider, CMS responded that the MACs will notify providers who submit directly and that:

  • A submitter is a clearinghouse, vendor or biller that submits to Medicare on behalf of one or more providers.

In addition, CMS clarified that the 90-day discretionary enforcement announcement requires submitters to test with their MACs, take action in regards to this plan and send it their transition plans. Medicare has developed the incremental steps in this plan to support the provider’s efforts in working with submitters.

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