HIPAA 5010 Transactions Standards & Code Sets (HIPAA 5010) readiness statement

On January 16, 2009, the U.S. Department of Health and Human Services (HHS) released the final rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regarding updated standards for electronic health care transactions: X12 Version HIPAA 5010.

MagnaCare Readiness

MagnaCare is committed to delivering excellent service and has adopted HIPAA transactions and code sets, including compliance with and support of HIPAA 5010.

Submit Your HIPAA 5010 Questions

Please note the replacement of the original base versions by the Errata in the chart below. Transactions not supported by MagnaCare are shown as “Not applicable.”

Transactions Affected by the Errata Errata Version
Compliance
January 1, 2012
Base Version
Compliance
January 1, 2012

820 Premium Payment

005010X218

Not Applicable

834 Benefit Enrollment and Maintenance

005010X220

005010X220A1

835 Health Care Claim Payment/Advice

005010X221

005010X221A1

837 Health Care Claim: Professional

005010X222

005010X222A1

837 Health Care Claim: Institutional

005010X223

005010X223A2

837 Health Care Claim: Dental

005010X224

Not Applicable

270/271 Health Care Eligibility Benefit Inquiry and Response

005010X279

Payor ID: MAGNA
Realtime service through Change HealthCare

276/277 Claim Status Inquiry/Response

005010X212

Payor ID: MAGNA
Realtime service through Change HealthCare

278 Health Care Claim Services Requests for Review and Response

005010X217

Not Applicable

999 Implementation Acknowledgement For Health Care Insurance

005010X231

005010X231A1

The final rule adopts X12 Version 5010 Errata for HIPAA transactions.

Modifications were introduced as a result of the current 4010A1 electronic transaction standards being outdated and including rules that no longer align with business practices in the health care industry.

The HIPAA 5010 final rule applies to all HIPAA covered entities, including health plans, health care clearinghouses, and certain health care providers. Version 5010 is designed to bring a more consistent use of health care transactions to the industry, ultimately making it easier for health care providers to submit the same information to all insurance carriers.

5010 Readiness FAQ

HIPAA X12 version 5010 is a set of standards that regulates the electronic transmission of specific healthcare transactions, including eligibility, claim status, referrals, claims, and remittances. Covered entities, such as health plans, healthcare clearinghouses, and healthcare providers, are required to conform to HIPAA 5010 standards. Use of the 5010 version of the X12 standards is required by federal law. The compliance date for use of these standards is January 1, 2012.
All covered entities, listed below, are required to upgrade to HIPAA 5010 standards. Covered entities may use a clearinghouse assist them with complying with the rules.
  • Physicians
  • Hospitals
  • Payers
  • Clearinghouses
Additionally, even though software vendors are not included in the list of covered entities, in order to support their customers they will need to upgrade their products to support HIPAA 5010 as a business imperative.
  • The ability to support new requirements brought forward by the industry
  • Clarification of usage to remove ambiguity
  • Consistency across transactions
  • Support of the NPI regulation
  • Removal of data content that is no longer used
The upgrade to HIPAA 5010 was important for several reasons:
  • Industry experience with the 4010A1 implementation uncovered some unanticipated issues and requirements; and
  • HIPAA 5010 will be able to accommodate the forthcoming and mandatory ICD-10-CM and ICD-10-PCS code sets, which were implemented on Oct. 1, 2013.
One of the most prominent challenges is identifying the gaps between HIPAA 4010A1 and 5010. Many of the challenges facing the healthcare industry are not technical in nature but address business challenges.
An organization should make it a priority to perform a thorough systems inventory to establish which technical and business components will be impacted by the transition to HIPAA 5010. In the analysis of business components, the organization should also review the readiness of their business partners, including clearinghouses, software vendors, etc., to confirm that they are also prepared to transition by the compliance date. Additionally, covered entities should perform a full internal gap analysis between HIPAA 4010A1 and HIPAA 5010. Such an analysis both focuses on a covered entity’s actual use of the content within the standard transactions and identifies the circumstances in which the changes in the standards impact the specific covered entity. This information will be vital in understanding the local impact of the transition to the organization.
The benefits specified in the member’s documents are unaffected by the HIPAA Title II mandate. HIPAA brings additional added-value, including safeguarding protected health information. However, if the group makes a change to the benefits it will be separate from the HIPAA update.
Yes, provided you have an established direct connection with MagnaCare and are not using a clearinghouse or billing service.
MagnaCare has offered testing of 5010 transaction sets with its trading partners since October 2011.
MagnaCare’s 5010 contact for questions and test files: [email protected]

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