Additional Health Insurance Portability and Accountability Act (HIPAA) 837 5010 Transitional Changes and Further Modifications to the Coordination of Benefits Agreement (COBA) National Crossover Processing

Supplemental payers are transitioning to HIPAA 5010 or National Council for Prescription Drug Programs (NCPDP) D.0 under the National Crossover Process. Currently, the Centers for Medicare & Medicaid Services (CMS) is transitioning supplemental payers that participate in the national Coordination of Benefits Agreement (COBA) crossover process from their production version 4010A1 HIPAA 837 claims to HIPAA versions 5010A1 and 5010A2 837 claims. As COBA supplemental payers move into production on the 5010A1 and A2 claim formats, CMS requires that they continue to accept their “pre-HIPAA 5010” production version 4010A1 claims for 14 full calender days after their cut-over to the new claim formats.

The following is an example to further illustrate this point:

Payer A moved to HIPAA 5010 production on November 7, 2011. Medicare will then systematically transfer to Payer A all “clean” electronically received 4010A1 claims that are already on the payment floor and tagged for crossover as of November 3 & 4, 2011. Beginning with claims that CMS Coordination of Benefits Contractor (COBC) received that have a file date of November 22, 2011, Meidcare, through the COBC, will no longer be able to transfer production 4010A1 claims to payer A. This is because 14 full calendar days have elapsed since Payer A moved into production on the HIPAA 5010 claim formats.

Note : The same premise will hold for inbound version 5.1 batch National Council for Prescriotion Drug Programs (NCPDP) claims when a supplemental payer moves into production on the NCPDP D.0, version 5.2 batch format for receipt of crossover claims.

As provided in CMS Change Requests (Crs) 6658* and 6664*, the COBC activates the following edits once COBA trading partners move into HIPAA 5010 or NCPDP D.0 production

  • N22226- “4010A1 production claim received, but the COBA trading partner is not accepting 4010A1 production claims.”

  • N22230- “NCPDP 5.1 production claim receive, but the COBA trading partner is not accepting NCPDP 5.1 production claims”.

Provider, physicians and suppliers should note that they will see the foregoing edit codes on the special provider notification letters that Medicare mails to them at their on-file correspondence address when Medicare is unable to send various claims for crossover purpose. Receipt of these codes on the special provider notification letters denotes that:

1. The patient’s supplemental payer has moved into HIPAA 5010 or NCPDP D.0 production receipt for all Medicare crossover claims; and

2. For a limited timeframe (likely 30 days after a supplemental payer cuts over to version 5010 for crossover claims receipt), providers, physicians, and suppliers will need to file the affected claims directly with their patients’ supplemental payers.