Are You Preparing for HIPAA2?
The Health Insurance Portability and Accountability Act of 1996 mandated that the healthcare industry use standard formats for electronic claims and claims related transactions. The Secretary of the Department of Health and Human Services (HHS) has adopted ASC X12 version 5010 and NCPDP version D.0 as the next HIPAA standard for HIPAA covered transactions on January 16, 2009. The final rule was published, and the Health and Human Services Administration issued regulation specifying that updated versions of the standards must be adopted by the industry. Currently, the Centers for Medicare & Medicaid Services (CMS), Medicare contractors and standard system maintainers are underway with implementation activities for 5010. Transition to the new formats for Medicare FFS will start on January 1, 2011, and must be completed by January 1, 2012. Medicare does not anticipate extensions to these deadlines.
The formats currently used must be upgraded from X12 Version 4010A1 to 5010
- Claim (837-I, 837-P, 837-I COB, 837-P COB, NCPDP),
- Remittance (835),
- Claim Status Inquiry/Response (276/277),
- Eligibility Inquiry/Response (270/271).
Systems that submit claims, receive remittances, exchange claim status or eligibility inquiry and responses must be analyzed to identify software and business process changes. CMS has prepared a side-by-side comparison of the 4010A1 and 5010 ASC X12 claim, remittance, claim status and eligibility inquiry/response versions are available on the CMS Website:
http://www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp 
New ASC X12 standard acknowledgement (999) and rejection transactions (TA1) will be utilized. Additionally the Claims Acknowledgement (277-CA) will be used to replace proprietary error reporting (e.g. prepass report).
Billing staff will likely need reports to be produced using the 999 and 277CA transaction in order to identify claim corrections before resubmission. Clearinghouses and Vendors may consider offering a 999 and 277CA reporting capability.
Additional Information regarding 5010:
- Purchase of Implementation Guides and access to Technical Questions X12:
http://www.x12.org/ - CMS Website for industry-wide information:
http://www.cms.hhs.gov/Versions5010andD0/
http://www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp
Transition to the new formats must be completed by January 1, 2012. Medicare does not anticipate extensions to these deadlines. If you rely on your vendor or clearinghouse to maintain your billing system and keep you up-to-date with electronic transactions, you need to ask your vendor and or clearinghouse about their plans for transitioning to the new 5010 format. If you fail to prepare, you may not be able to send electronic claims or receive electronic remittances, significantly impacting your business and cash flow.
Page Last Updated: Thursday, 18-Mar-2010 05:56:19 CDT
