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

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]