5010 Enforcement Effective June 30th — Key Transaction Changes

The deadline for medical providers serving Medicare to upgrade to the new 5010 system was January 1st, 2012.  CMS has subsequently moved the enforcement of the new system back to June 30th, 2012 due to issues with providers becoming acclimated to the new system.  Below are a few specific changes you should be aware of when transitioning to the new system to avoid unnecessary claim rejections from the CMS Provider website.

  1. ZIP Code: You need to include a complete 9-digit ZIP code for the billing provider and service facility location. You should work with your vendor to make sure that your system captures the full 9-digit ZIP. 
  2. Billing Provider Address: You need to use a physical address for your Billing Provider Address. Version 5010 does not allow for use of a PO Box address for either professional or institutional claim formats. You can still use a PO Box, however, as your address for payments and correspondence from payers as long as you report this location as a pay-to address.
  3. National Provider Identifier (NPI): You were previously allowed to report an Employer’s Identification Number (Tax ID) or Social Security Number (SSN) as a primary identifier for the billing provider. For Version 5010 claims, however, you are only allowed to report an NPI as a primary identifier.

For additional help with your Version 5010 upgrade and Medicare claims, you can contact your Medicare Administrative Contractor (MAC). The MACs work closely with clearinghouses, billing vendors, and health care providers who require assistance in submitting and receiving Version 5010 compliant transactions. If you experience difficulty reaching a MAC, you should send a message describing your issue to ProviderFeedback@cms.hhs.gov with “5010 Extension” in the subject line.

The Medicare Fee-For-Service group has created a fact sheet that provides guidance to help providers troubleshoot some of the difficulties they may experience with Version 5010 claims processing and links to each of the MAC websites, including lists of the top 10 edits for Version 5010 claims.


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