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HIPAA 5010 Implementation

The CMS Office of E-Health Standards & Services (OESS) is responsible for the policies and enforcement of the Administrative Simplification provisions for transactions and code sets and the National Provider Identifier (NPI) covered under the Health Insurance Portability and Accountability Act (HIPAA).

HIPAA 5010 was adopted to replace the current version of the X12 standard that covered entities (health plans, health care clearinghouses, and certain health care providers) must use when conducting electronic transactions. Version 4010 is currently being used under HIPAA standards.

Although HIPAA version 5010 gets much less notoriety than ICD-10 it is just as important and practices should already be working with vendors on the version 5010 implementation.

All practices should be utilizing 5010. The effective date for 5010 implementation was slated for January 1, 2012, however, enforcement on penalties was delayed. CMS recently issued the following update:

CMS is pleased to report that the vast majority of provider claims are being sent to Medicare in 5010 format. Given these favorable results, we are taking the next step towards full implementation of 5010 in Medicare Fee-For-Service (FFS).

Effective Sunday, April 1, 2012, your Medicare FFS transactions must be in 5010 format. Transactions placed in 4010 formatting will be returned as unprocessable. Failure to submit 5010 formatting will result in your claim being unpaid/denied.

Medicare FFS transition statistics are available for download. These statistics represent the transition from the current Health Insurance Portability and Accountability Act (HIPAA)-adopted Accredited Standards Committee (ASC) X12 Version 4010A1 and the National Council for Prescription Drug Programs (NCPDP) Version 5.1 transactions to the updated HIPAA ASC X12 version 5010 and NCPDP version D.0 transactions. The transition statistics cover the following:

  • Part A Claims and Remittances
  • Part B/DME Claims and Remittances
  • NCPDP Claims
  • Eligibility Inquiries and Responses
  • Claim Status Inquiries and Responses

If you have been lagging and are not 5010 compliant the following tips will help you expedite compliance.

CMS offers great strategy for preparing for 5010 Implementation:

  • Current transaction versions must be upgraded to Version 5010 and D.0. Medicare has performed a side by side comparison of the current 4010A1 and 5010 base formats found at: www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp The side by sides do not include errata changes and do not replace the TR3s. To purchase TR3s and access Technical QuestionsX12 please go to www.x12.org  or for NCPDP D.0 go to www.ncpdp.org.
  • Software must be modified to produce and exchange the new formats (e.g. trading partners must be able to read incoming 277CA transactions sent from Medicare).
  • Review business processes to ensure changes are not necessary to capture additional data elements not previously required (e.g. Impact of patient registration, billing, and claim reconciliation).
  • Contact your vendor and/or clearinghouse to ensure products and processes are updated (e.g. license includes regulation updates, and will the upgrade include acknowledgement transactions 277A & 999).
  • Trading Partners should contact their local Medicare-Fee-For-Service contractor (MAC) for specific testing schedules. See http://www.cms.gov/ElectronicBillingEDITrans/ under downloads, to find a MFFS contractor in your state, or find your operational MAC on this list. For details on testing requirements see the 5010 National Call presentation on Provider Outreach and Education – Transition Year Activities found at http://www.cms.gov/Versions5010andD0/downloads/OE_National_Presentation_12-8-10.pdf.