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 healthcare 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.
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 |
|
|
835 Health Care Claim Payment/Advice |
005010X221 |
|
|
837 Health Care Claim: Professional |
005010X222 |
|
|
837 Health Care Claim: Institutional |
005010X223 |
|
|
837 Health Care Claim: Dental |
005010X224 |
Not Applicable |
|
270/271 Health Care Eligibility Benefit Inquiry and Response |
005010X279 |
Payor ID: MAGNA |
|
276/277 Claim Status Inquiry/Response |
005010X212 |
Payor ID: MAGNA |
|
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Modifications were introduced as a result of the current 4010A1 electronic transaction standards being outdated and including rules that no longer align with business practices in the healthcare industry.
The HIPAA 5010 final rule applies to all HIPAA covered entities, including health plans, healthcare clearinghouses, and certain healthcare providers. Version 5010 is designed to bring a more consistent use of healthcare transactions to the industry, ultimately making it easier for healthcare 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.
There are changes across all of the transactions, some of which include:
- 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.
MagnaCare uses the following transaction sets:
- Health Care Claims Institutional(837I) Companion Guide (506KB)
- Health Care Claims Professional (837P) Companion Guide (458KB)
- Health Plan Enrollment & Maintenance (834) Companion Guide (271KB)
- Health Care Claim Payment/Remittance Advice (835) Companion Guide (533KB)
- Health Care Claim Status Response (277) Companion Guide (180KB)
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]