This version has the required claim change beginning January 1, 2012.
All current electronic claims are sent in a “4010-Format”. Effective January 1st 2012, the 4010 will be replaced by the “5010-Format.” The “5010-Format” allows for faster and clearer communication of eligibility and payment status.
Has the TCMS 5010-Format been tested?
Criterions is certified by Claredi, NGS/Medicare, NJ Medicare, Emdeon and McKesson for the “5010-Format”. Claredi is the gold standard for national uniformity for electronic claims. Our participation was optional but done to ensure that your file submissions will be successful.
Do practices using TCMS need to send TEST files?
Agreements with Emdeon, McKesson, NGS/Medicare, NJ Highmark Medicare, Connecticut Medicare, Empire BCBS, North Carolina BCBS and NY Medicaid have exempted Criterions submitters from sending TEST claim files.
If you wish to submit a TEST file (optional in most instances) to any Claim Center, please read below. Please realize that there is no need or requirement to send a TEST file or to edit these settings to begin submitting 5010-Format claim files in PRODUCTION.
What are the TCMS settings that affect the format of a generated 5010-Format file?
There are only two settings in TCMS that will affect the format of a file:
(a) Generating a 5010-Format file: There is a new Practice Default labeled “Generate 5010 Claims” that is ALREADY selected when you update to TCMS version 4.7.1. When this option is selected, claim files are created in the new 5010-Format; conversely, when it is not selected, claim files are created in the older 4010-Format.
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(b) Generating a TEST claim file: Each Claim Center in the EMC Setup screen contains a field labeled “ISA15_5010” that ALREADY contains a “P” when you update to version 4.7.1. The “P” will generate the Claim Center’s file in PRODUCTION mode. Conversely, a “T” will generate a Claim Center’s file in TEST mode.
What must a Practice do before sending claims as usual in 5010-Format?
Prior to submitting any claims in the new 5010-Format, these steps must be performed:
Step 1 – Go to your Practice Information screen and make sure there is a nine-digit zip-code in place for the Practice.
Step 2 – FOR P.O. BOX PAY-TO ADDRESSES ONLY:
The Practice Address cannot be a PO Box address; it must be a physical street address. If your Practice utilizes a PO Box as a pay-to address, place a check-mark in the “Pay-to-address (PO Box address)” field at the bottom of the Practice Information screen and proceed to enter the PO Box Address information.
Step 3 – Go to each Facility in your Practice and make sure there is a nine-digit zip-code in place for each Facility.
Step 4 - Install the new MSI on any workstation that will be used to create EMC files or to post ERN payments. This install is VERY EASY for you to do yourself and we will provide you with a guide in a TCMS Alert on Friday 12/23.
Are there any new agreements required by NGS or NY Medicaid?
Yes:
FOR NGS/MEDICARE SUBMITTERS ONLY:
A practice can submit claims in the new 5010 format immediately. However, NGS requires that you complete a detailed online agreement within the next few months (click here for the application). We are also providing you with a guide (click here for a step-by-step GUIDE to the application; click the guide to enlarge) intended to assist you in completing this agreement. Once this agreement is completed, the primary contact that you list within the agreement will be notified by e-mail (about a week later) with a confirmation that the agreement was processed by NGS. It is imperative that the Practice completes this agreement to avoid recertification next year.
FOR EMEDNY SUBMITTERS ONLY:
EMedNY requires that, if you want to receive the NY Medicaid remittance advice, you complete an “Electronic Remittance Request Form” (click here for the NY Medicaid application). The form can be completed and mailed, faxed or emailed to Computer Sciences Corporation (details in the form). Be sure to complete the form completely to avoid delays.
