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What you need to know about HIPAA 5010


What is HIPAA 5010?

In January 2009, CMS mandated versioning for format 5010 for all HIPAA transaction sets.  All Healthcare Providers, Payers, and Clearinghouses currently submitting HIPAA 4010A1 are required to submit under the new version as of January 1, 2012.  The new version is the next step in implementing Administrative Simplification and to provide a more efficient process.

In 2010 Fiscal Intermediaries tested to ensure processing of the new implementations.  Starting January 1, 2011, Healthcare Providers can begin testing their ability to submit successful 5010 transaction sets.

Version 5010 includes:

  • General Enhancements across all HIPAA standards
  • Consistent TR3 formats and implementation instructions
  • Approximately 500 industry requests addressed
  • Should reduce dependence on Fiscal Intermediary specific Companion Guides
  • Support for ICD-10 (Due in 2013)

Does HIPAA apply to me?

HIPAA 5010 applies to anyone filing electronic transactions.   The main thing that matters is whether the provider bills on a UB04 or CMS1500 form.  These relate to the different electronic formats Institutional and Professional, respectively.  Both conversions will be provided in Vision by HealthMEDX.  If the conversion to HIPAA does not occur, you may not be able to file claims or receive reimbursement.

When is HIPAA 5010 effective?

HIPAA 5010 must be implemented by January 1, 2012.  HIPAA 4010A1 will not be valid after that date and if HIPAA 5010 is not implemented, providers will not be able to file claims or receive reimbursement.  

How You Can Prepare:

  • Talk to your vendor – HealthMEDX has a plan in place to convert over all currently covered 835 and 837 transactions.
  • Talk to your clearinghouse – Ask about upgrades/fees and when you will be able to test the new transaction sets.
  • Check changes to data reporting requirements – For example in Professional claim transactions the billing provider address can no longer be a P.O. Box or Lockbox.
  • Talk to you FI – Find out testing requirements and timelines.  How early will your FI start accepting 837 5010, or providing 835 5010?
  • Test – Allot enough time to test the new transaction sets prior to 1/1/12.

What should I be asking my vendors and partners to ensure we’re prepared?

Ask your billing intermediaries when they will be ready to test, what the process is for testing, and if there are any specific requirements they need to be aware of.

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