ANSI 5010


The switch from the current 4010A1 format to the new 5010 format requires substantial changes to the claims information you submit. It is extremely important that you are aware of these HIPAA changes and take the necessary steps to be in compliance by the January 1 deadline. If these changes are not made, payers may not be able to process your claims.

The Centers for Medicare and Medicaid Services (CMS) mandate includes upgrading the current electronic transaction standard for health care claims, remittance advices, eligibility and claims status to X12 version 5010. Since the changes cover the data you submit with your claims as well as the data you receive in response to your electronic inquiries, implementation may require changes to the software, systems and procedures you use for billing your transactions.

MedExperts is here to help you through the 5010 conversion process. From helping test your claims to providing strategies to minimize the impacts to your practice, we are ready to ensure that your practice’s transition proceeds seamlessly and on time.

To assist you with planning a smooth transition, some of the following CMS guidelines outline questions to consider with your team. These steps will help identify actions for your office to take prior to the transition, plans for coordinating with your software vendors, clearinghouses, billing services, and payers, and impacts on your practice’s data reporting requirement changes, workflow modifications and testing.

Talk to your software vendor (MedExperts) early: Your software vendor is the company that supports your practice management system. You will need to contact them to determine what version you are currently using and what you will need to be 5010 compliant. Questions to consider asking:

·         Will you be upgrading your current system to accommodate Version 5010 transactions?

·         What is the time frame for when you will be able to support Version 5010 transactions?

·         Will you be able to support both Version 4010A1 and Version 5010 transactions at the same time?

·         When will upgrades be available?

·         Will there be a charge for upgrades or will my current charges increase?

·         When will software installations be completed for Version 5010?

·         If there will be an update to our system, what fields are being added or changed?

·         What business processes will be affected by 5010?

Identify changes to data reporting requirements: Data reporting requirements and questions for your own team to consider include:

·         What data reporting changes will affect the transactions we use?

·         What resources can we use to help us identify the data reporting changes? Will there be a cost?

·         Can the new data be stored in our office’s current system or will it require a system upgrade?

·         If our software vendor stated that there will be an update to our system, what fields are being added or changed?

·         How do these changes fit into our existing operations?

·         Will we need to purchase additional hardware for the new reporting requirements?

·         Based on data changes needed for our practice, does anyone in our office need to be trained on workflow changes?

·         Which requirements for testing 5010 transactions are relevant to our work?

·         What kinds of transactions do we need to have tested?

·         Do our vendors’ testing plans cover all of our needs?

Talk to your trading partners: Trading partners include all organizations involved in the end-to-end exchange of electronic health care data and transactions, such as payers, providers, clearinghouses, billing services, network service vendors and data transmission services. If you utilize a billing service, you need to contact them to determine their plan for 5010. If you send claims directly to any payers, you will need to contact them. 

To help you plan these conversations, questions to consider asking your trading partners include:

·         Will you be upgrading your systems to accommodate 5010 transactions?

·         When will each of the upgrades be completed?

·         Will there be additional fees for these upgrades?

·         Do the upgrades require changes to the way we work with you today?

·         When can we test for 5010 to ensure the system works properly?

·         Do you have connections to multiple trading partners and will you be testing with all of them?

·         Do we need to use test data or live data during testing?

·         What are your requirements for testing 5010 transactions?


Plan your next steps: Testing is a very important part of the transition to 5010. Gateway EDI is here to help with testing your claims and every stage of your 5010 transition. For answers to common questions about the transition and testing for 5010, please call us at:

1-866-871-0952 (option 2)



The following resources also offer assistance regarding the 5010 transition:

·         CMS Side-by-Side Comparison Documents for the 5010

·         The American Medical Association (AMA) – 7 Steps Practices Can Take Now to Prepare for 5010