HIPAA 5010

Overview

The U.S. Department of Health and Human Services has adopted the 5010 version as the standard format for electronic health claim transactions. HIPAA Version 5010 replaces Version 4010/4010A1 standards, and accommodates ICD-10 code sets.

LifeWise has a corporate-wide business plan for achieving full compliance with the electronic healthcare transactions requirements and all LifeWise applications that involve employer groups, contracted providers (physicians, dentists, hospitals), vendors, and trading partners.

Following are key dates for the transition from version 4010A1 to 5010:

  • Payers to begin Trading Partner testing on Jan. 1, 2011
  • Compliance testing completed by Dec. 31, 2011
  • Full transition compliance for all parties expected by Jan. 1, 2012

HOW CAN MY PROVIDERS ORGANIZATION PREPARE?

  • Talk with your practice management system vendors about accommodations for Version 5010
  • Discuss your implementation plans with all your billing agents and payers to ensure a smooth transition
  • Conduct testing with payers and billing agents using Version 5010
  • Stay up-to-date on resources and information from CMS

RESOURCES

CMS Version 5010 Web site 

Note: This section is for informational purposes only and is not intended as legal advice. It is an overview and is not comprehensive—created as a courtesy to providers.

LifeWise makes no representations or guarantees that the information concerning HIPAA is accurate or complete. 

Please contact your attorney for legal advice.

Administrative Simplification 

The Administrative Simplification part of HIPAA aims to reduce administrative costs in the healthcare industry through adopting and using standardized, electronic transmission of administrative and financial data.

Benefits of Administrative Simplification 

  • Reduces overall healthcare costs
  • Standardizes many administrative tasks in the healthcare industry
  • Protects against fraudulent billing practices
  • Protects individuals and their PPI
  • Protects members' rights through greater access to their health information
  • Potentially improves medical care through better data exchange between providers and payers

Administrative Simplification can be broken down into five key elements:

  • Privacy
  • Security
  • Standardized Transactions
  • Standardized Code Sets
  • Unique Identifiers

Privacy 

HIPAA privacy regulations require compliance with standards that protect the privacy of PPI. These rules include strict limits on how information can be used and disclosed.

Security 

HIPAA's Administrative Simplification provisions also require compliance with security standards related to PPI that is transmitted or stored electronically. The regulations include requirements for physical, technical and procedural safeguards to keep electronic healthcare information secure.

Standardized Transactions 

Covered healthcare providers, healthcare payers and healthcare clearinghouses must use "standard" formats to exchange healthcare transactions electronically.

The standard formats for HIPAA transactions are the American National Standards Institute (ANSI) ASC X12N, Version 4010A1. These formats apply to the following common business functions:


Transaction Name Number
Healthcare Claims 837
Healthcare Claim Payment/Advice 835
Payroll Deducted and Other Group Premium Payment 820
Benefit Enrollment and Maintenance 834
Healthcare Services Review 278
Healthcare Eligibility Benefit Inquiry and Response 270/271
Healthcare Claim Status Request and Response 276/277

Standardized Code Sets 

Electronic data exchange requires using standard code sets. The medical code sets used to identify data include:

  • ICD-9 for diseases
  • CPT-4 for services and procedures
  • HCPCS for medical equipment, injectable drugs and transportation services
  • NDC for prescription drugs
  • CDT-3 for dental services

The non-medical code sets include codes for place of service, revenue codes, relationship codes and more.

Unique Identifiers 

There are standard national identifiers for providers and employers. These "unique identifiers" will permit electronic data exchange and matching for all health insurance related transactions.

NPI Compliance 

You should include your NPI number now in HIPAA standard electronic transactions. Your Tax Identification Number (TIN) is still required for the ‘Bill To’ or ‘Pay To’ provider.

Refer to the Centers for Medicare and Medicaid Services (CMS) National Provider Identifier Standard (NPI) web site for information on:

  • Applying for NPI Online
  • Current news about NPI implementation for providers
  • Links to educational resources
  • Instructions on how to apply for an NPI
  • “Medlearn Matters” articles on NPIs

You can request a printed application:

In addition, physicians and providers now have the ability to enter their NPI with specific demographic data through OneHealthPort. The information will be shared in an electronic file to each of the participating health plans. At OneHealthPort, you can register with an ID and password if you do not already have one, and access the link to the NPI entry area.