​HIPAA 5010​

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Beginning on January 1, 2012, a federal mandate requires health plans, clearinghouses, and providers to use new standards in electronically conducting certain health care administrative transactions at the heart of daily operations, including claims, remittance, eligibility, and claims status requests and responses. Upgrading from the current HIPAA 4010A1 transaction standards to the new 5010 standards addresses several key goals:

    
        Increase transaction uniformity
        Support pay for performance
        Streamline reimbursement transactions

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As the deadline approaches, affected health care organizations need to upgrade and test their claims management systems to accommodate 5010 and prevent operational disruptions.
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The need for change

Two key factors prompted the upgrade to 5010:

        the government and industry’s shared goal of providing higher quality, lower cost health care, and
        the need for a comprehensive electronic data exchange environment for the vastly expanded ICD-10-CM and PCS code set transition mandated for compliance by October 1, 2013.

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Consistent compliance standards are critical to both objectives.

The 4010 compliance standard was not fully enforced, and many proprietary adaptations were implemented, forcing providers to interpret and reconcile disparate billing and reimbursement processes and systems.

It is estimated that up to 20 percent of premium dollars are spent on these administrative expenses, due to numerous manual processes. Overall healthcare costs and bottom line improvements may be achieved with the implementation of the new code sets.
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5010 from your vantage point

According to the federal timeline, organizations should be nearing completion of level 1 testing in late 2010 and beginning testing with trading partners in January 2011. Health care organizations need to implement new electronic transaction software that can handle the upgrade, in order to comply with the CMS mandates.

“All hospitals, physicians, health plans, and others can use the new code sets, if they first upgrade their electronic systems to be compatible”.

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Proactive organizations that use the latest technology solutions, and meet the CMS deadlines, will realize the benefits associated with 5010 implementation more rapidly.

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How can health organizations do this?

Inventory your systems to determine which ones will be impacted by the change, communicate with information systems vendors to determine whether upgrade plans are sufficient, evaluate clearinghouses and other business partners to gauge 5010 readiness, and test, certify and validate all your EDI transactions for compliance. To learn more, follow the links below.

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What is version 5010 of the X12 HIPAA Transaction and Code Set Standards?

HIPAA X12 version 5010 and NCPDP version D.0 are new sets of standards that regulate the electronic transmission of specific healthcare transactions, including eligibility, claim status, referrals, claims, and remittances. Covered entities, such as health plans, healthcare clearinghouses, and healthcare providers, are required to conform to HIPAA 5010 standards.

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The current transaction standard is the X12 version 4010A1 for eligibility, claims status, referrals, claims, and remittances; similarly, the current standard is NCPDP version 5.1 for pharmacy claims.

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Use of the 5010 version of the X12 standards and the NCPDP D.0 standard is required by federal law. The compliance date for use of these standards is January 1, 2012.

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Who will need to upgrade to HIPAA 5010?

All covered entities, listed below, are required to upgrade to HIPAA 5010 standards; covered entities may use a clearinghouse assist them with complying with the rules.

        Physicians
        Hospitals
        Payers
        Clearinghouses
        Pharmacies
        entists
     

What transactions are specified in the HIPAA 5010 standards? 

        270/271 – Health Care Eligibility Benefit Inquiry and Response
        276/277 – Health Care Claim Status Request and Response
        278 – Health Care Services – Request for Review and Response; Health Care Services Notification and Acknowledgment
        820 – Payroll Deducted and Other Group Premium Payment for Insurance Products
        834 – Benefit Enrollment and Maintenance
        835 – Health Care Claim Payment/Advice
        837 – Health Care Claim (Professional, Institutional, and Dental), including coordination of benefit
        COB) and subrogation claims
        NCPDP D.0– Pharmacy Claim
     

Where can the Technical Reports (Implementation Guides) be obtained?

The Technical Reports (TR3 Documents) and their addenda are available for purchase in the X12 Store located at

These TR3 documents are listed as follows:

    
        X217 – Health Care Eligibility Benefit Inquiry and Response 270/271
        X212 – Health Care Claim Status Request and Response 276/277
        X215 – Health Care Services – Request for Review and Response 278
        X216 – Health Care Services Notification and Acknowledgment 278
        X218 – Payroll Deducted and Other Group Premium Payment for Insurance Products 820
        X220 – Benefit Enrollment and Maintenance 834
        X221 – Health Care Claim: Payment/Advice 835
        X222 - Health Care Claim: Professional 837
        X223 – Health Care Claim: Institutional 837
        X224 – Health Care Claim: Dental 837
     

What are the major differences between HIPAA 4010A1 and HIPAA 5010?

There are changes across all of the transactions, some of which include:

    
        The ability to support new-use cases brought forward by the industry
        Clarification of usage to remove ambiguity
        Consistency across transactions
        Support of the NPI regulation
        Removal of data content that is no longer used
     

Why was it necessary to upgrade to HIPAA 5010?

The upgrade to HIPAA 5010 was important for several reasons:

    
        Industry experience with the 4010A1 implementation uncovered some unanticipated issues and requirements
        HIPAA 5010 will be able to accommodate the forthcoming and mandatory ICD-10-CM and ICD-10-PCS code sets, which are scheduled to be implemented on Oct. 1, 2013
     

What challenges does HIPAA 5010 present to the healthcare industry?

One of the most prominent challenges is identifying the gaps between HIPAA 4010A1 and 5010. Many of the challenges facing the healthcare industry are not technical in nature but address business challenges.

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Because of our commitment to guiding our clients through this transition, we will be publishing on www.hipaasimplified.com a summary document of issues and challenges that face each segment of the industry today.

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How can covered entities prepare for the transition to HIPAA 5010?

An organization should make it a priority to perform a thorough systems inventory to establish which technical and business components will be impacted by the transition to HIPAA 5010. In the analysis of business components, the organization should also review the readiness of their business partners, including clearinghouses, software vendors, etc., to confirm that they are also prepared to transition by the compliance date. Additionally, covered entities should perform a full internal gap analysis between HIPAA 4010A1 and HIPAA 5010. Such an analysis both focuses on a covered entity’s actual use of the content within the standard transactions and identifies the circumstances in which the changes in the standards impact the specific covered entity. This information will be vital in understanding the local impact of the transition to the organization.

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Because of our commitment to guiding our clients through this transition, we will be publishing on www.hipaasimplified.com a generalized 4010A/5010 gap analysis for each HIPAA standard transaction that we support.

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Are there any milestones published by HHS to help organizations meet the compliance dates?

HHS has recommended the below timeline to help the industry migrate to the new versions of the transactions:

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