Below are answers to frequently asked questions about 5010 transaction standard and ICD-10.
Q: What is version 5010 of the x12 HIPAA transaction and code set standards?
A: Currently, the transaction standard in use is the X12 version 4010A1. The 4010 transaction standards drive billing, reimbursement, and administrative functions. CMS is requiring the industry to upgrade from the 4010 transaction standard to 5010. Therefore, HIPAA X12 version 5010 is the new set of standards that regulate the electronic transmission of specific health care transactions including eligibility, claim status, referrals, claims, and remittances.
Q: Is the 5010 conversion a mandatory change?
A: Yes. Use of the 5010 version of the X12 standard is required by federal law. The deadline to comply with HIPAA 5010 standards is January 1, 2012.
Q: Who will need to upgrade to HIPAA 5010?
A: All covered entities (includes health plans, health care clearinghouses, and health care providers) are required to upgrade to HIPAA 5010 standards; covered entities may use a clearinghouse to assist them with complying with the rules.
While software vendors are not included in the list of covered entities, they will also need to upgrade their products in order to support their customers.
Q: What are the benefits of the 5010 standards?
A: The 5010 standards promise many improvements to EDI transactions including greater clarity in provider loops and NPI instructions, reduced ambiguity among common data elements, and elimination of unnecessary or redundant data elements. It also provides support for the five-fold increase (from approximately 16,000 to over 65,000 codes) in the new ICD-10 code set. Switching to the HIPAA 5010 transaction sets for claims and related transaction will improve transaction uniformity, support pay-for-performance programs, and streamline reimbursement transactions.
Q: 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
- 835 – Health Care Claim Payment/Advice
- 837 – Health Care Claim (Professional, Institutional, and Dental), including coordination of benefits (COB) and subrogation claims
Q: What are CMS timelines for 5010 standards implementation?
Q: When will Ingenix clearinghouses be ready for testing and for which transactions?
|October 1, 2010
||Test the batch claims transactions (837P, 837I, and 837D) with trading partners
|October 1, 2010
||Test the response reporting 999, 277CA from/to trading partners
|January 1, 2011
||Test the 835, 270/271, 276/277, and 278 transactions with trading partners
|January 1, 2012
||5010 compliance date for all covered entities
|October 1, 2013
||ICD-10-CM and ICD-10-PCS compliance date
Q: Are the technical reports (implementation guides) available to the public?
The Technical Reports (TR3 Documents) and their addenda can be purchased from the Washington Publishing Company: http://www.wpc-edi.com/
These TR3 documents include:
- X222 – Health Care Claim: Professional (837)
- X223 – Health Care Claim: Institutional(837)
- X224 – Health Care Claim: Dental (837)
- X221 – Health Care Claims Payment/Advice (835))
- X279 – Health Care Eligibility Benefit Inquiry and Response (270/271)
- X217 – Health Care Services Review - Request for Review and Response (278)
Ingenix provides the solutions, consulting, and transaction testing services that health care organizations need to prepare for the industry’s implementation of the 5010 transaction standard.