What’s causing HIPAA 5010 rejections or denials


HIPAA 5010 standards have been used for a few weeks to transmit electronic medical claims. How's that working?

While it's tempting to assume that no news is good news, you should watch out for any medical claim rejections and denials. According to Ken Bradley, vice president of strategic planning at Navicure, problems have been exposed now that healthcare payers are dealing with a full load of medical claims.

Here are some of the problems that could be causing rejections or denials:

  • National Provider Identifiers (NPI) need to be used, not an employer’s tax ID or Social Security number.
  • HIPAA 5010 requires that a street address — not P.O. box — be used on all medical claims.
  • Providers can use a P.O. box for a billing address that receives reimbursement checks. But make sure the payers have that on file and are using it.
  • Speaking of addresses, providers need a nine-digit zip code with the billing and physical addresses.
  • HIPAA 5010 allows as many as 12 diagnosis codes on each claim, but each specific service can only have four codes.
  • Any claim using an unlisted Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code also needs a code description.
  • Healthcare providers must submit a Medicare Secondary Payer (MSP) indicator on the primary and secondary claim when Medicare is the secondary payer.
  • Drug quantity and unit of measurement are required when a National Drug Code (NDC) is listed.
  • All ingredients in a compound prescription must be listed with a HCPCS code.

In addition to watching the number of denials or rejections, make sure the reimbursements match what you expect. Bradley noted that getting claims out the door doesn't mean they will be reimbursed properly.

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