Skip to main content

5010 Transition

October 21, 2013

As everyone by now knows, there are serious issues facing the Community Health Center community.  These include declining budgets at both the local and federal levels, rising numbers of uninsured patients and increased scrutiny of the Medicare and Medicaid programs due to fraud and abuse.  The list of concerns for some CHCs unfortunately could fill a small book.  However, one which needs to be discussed imminently is the recent change in claim submission format v5010 and possible cash flow implications due to denied claims.  We have heard from a number of CHCs on the issue with a wide range of responses. 

The v5010 transition (i.e., the move from v4010 to v5010) has been well publicized and providers, including CHCs, had a significant amount of lead-time to prepare.  Every claim submitted to Medicaid, Medicare, and commercial carriers should be sent electronically in this new format.  Although minor differences exist, the claim data submitted to Medicaid in one state is quite similar to those submitted in another state.  The information included in the claim includes patient information, diagnosis code, procedure code, fee charged and sufficient accompanying information which allows the payer to pay or deny the claim.  The v5010 transaction set changed the format of this information from what had been sent for years.  For example a claim in this format resembles columns in a spreadsheet.  With the 5010 change, many of the columns contain new information or tweaked the old format.  Sound confusing?  It is. 

Good news – CMS extended the deadline for enforcing this change.  Although some CHCs have experienced cash flow issues since January 1, the majority have not.  Its time to ensure your organization has completed testing and communicated with essential parties (billing systems vendors, electronic claims clearinghouses, payers) to avoid unnecessary delays in payments.  For more information direct from CMS, see the following link:

As discussed the CMS extension expires as of March 31, 2012.  Time is of the essence!

Get the Latest RCM News Delivered

Receive practical tips on medical billing and breaking news on RCM in your inbox.

Get in Touch