HIPAA 5010

HIPAA 5010: On January 1, 2012, the health care industry will be required to conduct the current HIPAA electronic transactions, including claims submission, remittance advice, eligibility, claims status, referral authorizations, and others, using the upgraded 5010 version.

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

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

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.

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.

Who will need to upgrade to HIPAA 5010?

All covered entities are required to upgrade to HIPAA 5010 standards; covered entities may use a clearinghouse assist them with complying with the rules.  Examples of healthcare providers are physicians, hospitals, pharmacies, dentists, home health agencies, and, of course, all durable medical equipment (DMEPOS) suppliers.   Other covered entities include

Payers and clearinghouses

Additionally, even though software vendors are not included in the list of covered entities, in order to support their customers they will need to upgrade their products to support HIPAA 5010 and NCDPD D.0 as a business imperative.

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 benefits (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 http://store.x12.org/.

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

The NCPCP Documents are available for purchase on the NCPDP Website: http://www.ncpdp.org/standards_purchase.aspx.

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; and

• 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; and

• 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.

How can DMEPOS suppliers prepare for the transition to HIPAA 5010?

A home medical equipment 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, you 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.

5010 Implementation Steps: Getting the Work Done in Time for the Deadline

On January 1, 2012, the health care industry will be required to conduct the current HIPAA electronic transactions, including claims submission, remittance advice, eligibility, claims status, referral authorizations, and others, using the upgraded 5010 version.

The following is an overview of the work to complete the activities to help you become compliant. Some activities may be done at the same time. The amount of time it takes you to complete the various activities will depend on the size of your practice and available resources.

Follow these steps to successfully implement the 5010 transactions. Doing so will help you avoid rejected claims and cash flow interruptions.

Step 1 – Impact Analysis:

Become familiar with the upgrade and conduct an internal impact analysis to determine the impact the change to 5010 will have on your business practices and systems.

Step 2 – Contact your Vendors, Payers, Billing Service, and Clearinghouse:

Contact your vendors for specific details on the installation of upgrades to your system. Also, contact your clearinghouses, billing service, and payers for preliminary information on when they expect their upgrades will be completed and they will be ready to accept the 5010 transactions.

Step 3 – Installation of Vendor Upgrades:

Undergo installation of upgrades from your vendor. Keep in mind that the timing of the system upgrades will be dependent on your vendor’s readiness, both with respect to product development and scheduling.

Step 4 – Internal Testing and Staff Training:

Once the upgrades are completed, you will need to conduct internal testing of your systems to ensure you can generate the 5010 transactions. Allow extra time to resolve any issues that may arise and work with your vendor to address these.

You will also complete staff training throughout the process of implementing and testing your system.

Step 5 – External Testing with Clearinghouse, Billing Service, and Payers:

Contact your clearinghouses, billing service, and payers to conduct external testing with them. Testing with your trading partners (e.g., clearinghouses and payers) will ensure that you can send and receive the transactions properly.

Step 6 – Make the Switch to 5010:

After you have completed external testing with some or all of your trading partners, you may switch to using only the 5010 transactions. You are permitted to begin using the 5010 transactions prior to the compliance date, as long as you and the other organization are in agreement with the early conversion.

January 1, 2012

You must use only the 5010 transactions as of this date. The 4010 transactions will be non-compliant and will be rejected.

After January 1, 2012

Monitor the submission and receipt of 5010 transactions to ensure they are working properly.

October 1, 2013

The industry switches from the ICD-9 to the ICD-10 diagnosis and procedure code sets.

As you can see from the activities, there is much work to be done in a short period of time. Get started today on implementing the 5010 transactions to ensure you meet the January 1, 2012 deadline and do not suffer claim payment interruptions.

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