5010 - So What or Oh No!

Posted by Ron Decker on 10/07/2011

Ninety days and counting, what’s all the fuss?  In January 2009, the HHS Secretary adopted the changes to replace the current version of the X12 standards for covered entities as a part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  The regulations were adopted March 17, 2009 and Level I compliance began December 31, 2010 with Level II compliance by December 31, 2011[i], 86 days away, blah, blah, blah.  I know, “don’t you know I’m in health care, HIPAA is old news, we’re compliant with all of this stuff, and I don’t have time to mess with this”.

If your health care reimbursement is dependent on a third party payor paying a claim, you should take time to read the opening paragraph again.  Because if you haven’t confirmed that your covered entities, ie., software, billing company, and clearinghouse can handle the CMS changes, your “post-holiday” surprise may be lower reimbursement.   Oh but there’s more, once your covered entities have been confirmed, you must rely on reimbursement analytical tools to confirm that all your payors are paying to your pay to address.  This may actually be the biggest hurdle to overcome because of the changes in the address requirements under the regulations.

Below are three questions about the changes with regard to the “Billing Provider Address” in Regulation 5010 from a WEDI FAQ publication[ii].

  • Question: Can I report a PO Box address in the Billing Provider Address fields?
    • Response: No. The Billing Provider Address reported in N3 must be a street address.  This includes lock boxes or lock bins, and will obviously cause a problem if a provider or billing service has not made the necessary changes.


  • Question: I did not use my street address when I enrolled with my payers. Will this cause a problem?
    • Response: It might. Many payers use the address on their provider files that you provided at initial enrollment. You may not need to submit any changes to the payer if you want to receive payment exactly as you do today and you will be using the 5010 provider loops correctly.  These obviously should be reviewed if you have billing under a provider number/identifier that hasn’t been updated for some time.


  • Question: My current street address does not match my street address in the NPI database. Will this cause a problem?
    • Response: It might. Payers might use the NPI database, known as the National Plan & Provider Enumeration System (NPPES) update these as soon as possible.


Obviously, these changes will have an effect on many providers, billing companies and office staff, either directly or indirectly.   Innovative Healthcare Systems has been working on the 5010 project for many months.  We recognize that even with research, understanding and modifications to our system, when dependent on others to adopt change as well, that changes like these do not contain some risk.  Consequently, we have put in a second layer or contingency plan in place and are confident that we are ready.  For our clients, reimbursement is our greatest focus.  Providing peace of mind is a benefit that results from that focus.

For providers and billing staff, there will be no delay on the January 1st timeline.  Act now to contact your software vendor, billing company representative or clearinghouse.  You are the person that can determine whether winter 2012 will be a “So What or Oh No!”

© 2011 – Ron M Decker

Ron Decker’s Blog – rmdmusing

Twitter -  RonMDecker

[i] CMS – U.S. Dept. of Health & Human Services – Versions 5010 & D.0 & 3.0 – Overview

[ii] WEDI – 5010 837 – Billing Provider Address – Frequently Asked Questions – April 28, 2011

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