HIPAA 5010 & 837 Standard form

What is version 5010 of the X12 HIPAA Transaction and Code Set Standards? 

HIPAA X12 version 5010 and NCPDP version D.0 are new sets of standards that regulate 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. 

The current transaction standard is the X12 version 4010A1 for eligibility, claims status, referrals, claims, and remittances; similarly, the current standard is NCPDP version 5.1 for pharmacy claims. 

Use of the 5010 version of the X12 standards and the NCPDP D.0 standard is required by federal law. The compliance date for use of these standards is January 1, 2012. 

Who will need to upgrade to HIPAA 5010? 

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

                • Pharmacies

                • Dentists

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 and NCDPD D.0 as a business imperative. 

What transactions are specified in the HIPAA 5010 standards?

                • 270/271 – Health Care Eligibility Benefit Inquiry and Response

                • 276/277 – Health Care Claim Status Request and Response

                • 278 – Health Care Services – Request for Review and Response; Health Care Services Notification and Acknowledgment

                • 820 – Payroll Deducted and Other Group Premium Payment for Insurance Products

                • 834 – Benefit Enrollment and Maintenance

                • 835 – Health Care Claim Payment/Advice

                • 837 – Health Care Claim (Professional , Institutional, and Dental), including coordination of benefits (COB) and subrogation claims

                • NCPDP D.0– Pharmacy Claim

Where can the Technical Reports (Implementation Guides) be obtained?

The Technical Reports (TR3 Documents) and their addenda are available for purchase in the X12 Store located at http://store.x12.org/.

These TR3 documents are listed as follows:

                • X217 – Health Care Eligibility Benefit Inquiry and Response 270/271

                • X212 – Health Care Claim Status Request and Response 276/277

                • X215 – Health Care Services – Request for Review and Response 278

                • X216 – Health Care Services Notification and Acknowledgment 278

                • X218 – Payroll Deducted and Other Group Premium Payment for Insurance Products 820

                • X220 – Benefit Enrollment and Maintenance 834

                • X221 – Health Care Claim: Payment/Advice 835

                • X222 - Health Care Claim: Professional 837

                • X223 – Health Care Claim: Institutional 837

                • X224 – Health Care Claim: Dental 837

The NCPCP Documents are available for purchase on the NCPDP Website: http://www.ncpdp.org/standards_purchase.aspx.

HIPAA EDI standards (Version 4010/4010A1) with Version 5010

HIPAA Standards

The Centers for Medicare and Medicaid Services (CMS) is underway with implementation activities to convert from Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version D.0.

The Secretary of the Department of Health and Human Services (HHS) has adopted ASC X12 version 5010 and NCPDP version D.0 as the next HIPAA standard for HIPAA covered transactions. The final rule was published on January 16, 2009. Some of the important dates in the implementation process are:

Effective Date of the regulation: March 17, 2009
Level I Compliance by: December 31, 2010
Level II Compliance by: December 31, 2011
All covered entities have to be fully compliant on: January 1, 2012

Level I compliance means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing."
Level II compliance means "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards."
HHS permits dual use of existing standards (4010A1 and 5.1) and the new standards (5010 and D.0) from the March 17, 2009, effective date until the January 1, 2012 compliance date to facilitate testing subject to trading partner agreement.

The CMS Medicare Fee-for-Service schedule is :Level I April 1, 2010 through December 31, 2010

Level II January 1, 2011 through December 31, 2011

Fully compliant on January 1, 2012

CMS has prepared a comparison of the current X12 HIPAA EDI standards (Version 4010/4010A1) with Version 5010 and the NCPDP EDI standards Version 5.1 to D.0. The 4010A1 Implementation Guides and the 5010 Technical Report 3 (TR3) documents served as reference materials during the preparation of the comparison excel spreadsheets. The Data Interchange Standards

Association(DISA) holds a copyright on the TR3 documents: Copyright (c) 2009, Data Interchange Standards Association on behalf of ASC X12. Format (c) 2009, Washington Publishing Company. All Rights Reserved. The TR3 documents can be obtained at http://store.x12.org/

CMS is making the side-by-side comparison documents available to interested parties without guarantee and without cost. The documents are available for download in both Microsoft Excel and PDF formats. The comparisons were performed for Medicare Fee-for-Service business use and while they may serve other uses, CMS does not offer to maintain for purposes other than Medicare Fee-for-Service. Maintenance will be performed without notification, as needed to support Medicare Fee-for-Service.