Medi-Cal 5010 Delay Announcement


If you haven’t heard, Medi-Cal has announced that they will not accept claims submitted in the 5010 format after 1/1/12 and that providers should plan to continue to submit Medi-Cal electronic medical claims in the 4010 format for up to one year.

Medi-Cal 5010 Delay Letter

This presents some unique problems for California hospitals and other institutions where payer readiness is an issue.

What will happen at your facility when some payers require 5010 claims and others will not accept them?

Some possible solutions are:

  • Split the Claim formats by payer

If your system provides this feature.  This would allow you to submit 5010 and 4010 formats at the same time based on payer requirements.  If you don’t have this option, you will need to convert one of the formats to the other after the file is created.  This presents new problems and expenses if you are changing 4010s to 5010s or the reverse.

  • Send claims through a clearinghouse rather than direct to the payer.

This process will generate additional expenses, but may be your only option to get all claims paid given the time remaining.

Assess your situation and make sure you are prepared.

You should Know:

  • What Billing Format each Payer will accept after 1/1/12
  • Your Claim testing status 
  • Capabilities of your Medical Billing System
  • Payer Readiness

Don’t get caught submitting claims that will not be paid.

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