Understanding 5010
All electronic healthcare transactions (such as claims, ERA and eligibility) are transmitted in compliance with standards set forth by the Health Insurance Portability and Accountability Act (HIPAA) and the United States Department of Health and Human Services (HHS). On January 16, 2009, HHS announced a final rule that replaces the current version of these standards (4010A) with version 5010. The rule establishes that all covered entities should begin testing and migrating to 5010 during the 2011 calendar year in preparation for the final compliance date of January 1, 2012. Beginning on January 1, 2012, all electronic HIPAA transactions must be exchanged using the new 5010 standards.
What is HIPAA ANSI X12 5010?
First, the electronic transmission format currently mandated by HIPAA (ANSI X12 4010 A1) must be replaced by January 1, 2012 with ANSI X12 5010 ERRATA. This affects claims, remittances, eligibility requests, claims status, referrals and other HIPAA transactions. This format change is necessary to prepare for ICD-10 and to tighten up the HIPAA standards.
Considering the history of NPI and the original HIPAA implementation, CompuGroup Medical believes there will be a period of time when your practice will need to submit some claims under 5010 and other claims under 4010 (depending on payer readiness). Submitting via our clearinghouse means you will be able to send claims in either format and know when testing is completed. You will need to run the most current version of your CGM PM software (NetPracticePM, HPM, Alteer Office, Visionary Office, DAQbilling, The Medical Office, MENDS and PCN) to ensure you have all the necessary updates to support this mandate.
CompuGroup Medical Claim Validation Process
To provide our customers with the utmost confidence in our format, CompuGroup Medical has contracted with Claredi, the industry leader in comprehensive HIPAA testing. Claredi provides seven levels of edits from integrity of the file to codes sets.
The Claredi Certification seal provides confidence that the structure and data in a file are HIPAA compliant. Whatever product or service you use, your file will carry the confidence of Claredi certification.Beyond the Claredi process, we will also test with payers and trading partners that are able to accept the 5010 format to allow for certification and subsequent claim submission. This will continue throughout the year until January 1, 2012.
Key Dates
- January 1, 2011 CompuGroup Medical's Clearinghouse prepares for testing with payers that will accept the 5010 format
- Late Q2 2011 CompuGroup Medical to implement a dual system for sending 4010 and 5010 based on payer requirements with a centralized translation process
- January 1, 2012 CompuGroup Medical systems fully transitioned to 5010 and processing with new ANSI 5010 standards
- October 2014 ICD-10 code replaces ICD-9 code set
Practice Recommendations
We recommend that each practice understand the business impact of the 5010 enhancements and update your workflow to collect and enter incremental 5010 content. On receipt of 5010 updates, each practice should immediately install, train and begin using the updates. Some of the key changes you will notice:
- Billing provider address can no longer be a PO Box in 5010. Providers may want to contact their payer partners to determine enrollment impact before changing the address on claims;
- Zip Code must be nine digits in 5010 for Billing Provider and Service Facility;
- Some plans currently still require the Legacy ID, but providers can't send in 5010;
- For 5010 some plans are requiring NPI on the 270 and 276 transactions for the first time;
- Diagnosis Code occurrence is increased from 8 to 12 to prepare for the future conversion to ICD-10; and
- Patient Relationship Code Valid values increased to 23 in 4010 and reduced back to 8 in 5010.