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.
- 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
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
- 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.
We want your practice to have a smooth transition to 5010. If
you have any questions on the information in this handout, please
contact us here.