Why is it necessary to upgrade to HIPAA 5010?

The upgrade to HIPAA 5010 is required by federal law. In January 2009, the U.S. Department of Health and Human Services (HHS) announced a rule that mandates updated standards for electronic health care and pharmacy transactions. The upgrade to 5010 is important because the new version 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 is Version 5010 of the X12 HIPAA Transaction and Code Set Standards?

HIPAA X12 Version 5010 is a new set of standards that regulate the electronic transmission of specific health care transactions, including eligibility, claim status, referrals, claims, and remittances. Covered entities, such as health plans, health care clearinghouses, and health care 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. Use of the 5010 version of the X12 standards is required by federal law. The compliance date for use of these standards is Jan. 1, 2012.

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; and,  
• Dentists.

Additionally, even though software vendors are not included in the list of covered entities, it will be important for them to upgrade their products to support HIPAA 5010 as well in order to support their customers.

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; and,  
• 837 – Health Care Claim (Professional , Institutional, and Dental), including coordination of benefits (COB) and subrogation claims.

What are transaction “errata”?

Transaction errata are created by the X12 standards committee to resolve any errors found in the published “Technical Reports Type 3” (TR3s). Errata have been published for the 270/271, 835, and 837 I, P, and D and are now considered the compliant versions of those transactions under HIPAA. There is also an errata version of the 999.

Where can I find more information regarding the transaction “errata”?

Organizations that purchased TR3s can download transaction errata through Washington Publishing.  Additional background information on the errata can be found in the X12 TR3 newsletters located on the X12 website.

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.

How can your organization prepare for the transition to HIPAA 5010?

As an organization you 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.

Upcoming compliance milestones for HIPAA 5010

External Testing (errata version) – Q3 2011

Level II compliance – 12/31/2011

Fully Compliant – 01/01/2012  

Note: Catch Data Systems compiled these questions and answers after conducting a thorough search of widely used sources and then verifying for accuracy and relevance.  Copyright or ownership is not implied nor sought.