HIPAA 5010 AND CO-ORDINATION BENEFIT

Additional Health Insurance Portability and Accountability Act (HIPAA) 837 5010 Transitional Changes and Further Modifications to the Coordination of Benefits Agreement (COBA) National Crossover Processing



Supplemental payers are transitioning to HIPAA 5010 or National Council for Prescription Drug Programs (NCPDP) D.0 under the National Crossover Process. Currently, the Centers for Medicare & Medicaid Services (CMS) is transitioning supplemental payers that participate in the national Coordination of Benefits Agreement (COBA) crossover process from their production version 4010A1 HIPAA 837 claims to HIPAA versions 5010A1 and 5010A2 837 claims. As COBA supplemental payers move into production on the 5010A1 and A2 claim formats, CMS requires that they continue to accept their “pre-HIPAA 5010” production version 4010A1 claims for 14 full calender days after their cut-over to the new claim formats.



The following is an example to further illustrate this point:

Payer A moved to HIPAA 5010 production on November 7, 2011. Medicare will then systematically transfer to Payer A all “clean” electronically received 4010A1 claims that are already on the payment floor and tagged for crossover as of November 3 & 4, 2011. Beginning with claims that CMS Coordination of Benefits Contractor (COBC) received that have a file date of November 22, 2011, Meidcare, through the COBC, will no longer be able to transfer production 4010A1 claims to payer A. This is because 14 full calendar days have elapsed since Payer A moved into production on the HIPAA 5010 claim formats.



Note : The same premise will hold for inbound version 5.1 batch National Council for Prescriotion Drug Programs (NCPDP) claims when a supplemental payer moves into production on the NCPDP D.0, version 5.2 batch format for receipt of crossover claims.

As provided in CMS Change Requests (Crs) 6658* and 6664*, the COBC activates the following edits once COBA trading partners move into HIPAA 5010 or NCPDP D.0 production

• N22226- “4010A1 production claim received, but the COBA trading partner is not accepting 4010A1 production claims.”

• N22230- “NCPDP 5.1 production claim receive, but the COBA trading partner is not accepting NCPDP 5.1 production claims”.

Provider, physicians and suppliers should note that they will see the foregoing edit codes on the special provider notification letters that Medicare mails to them at their on-file correspondence address when Medicare is unable to send various claims for crossover purpose. Receipt of these codes on the special provider notification letters denotes that:



1. The patient's supplemental payer has moved into HIPAA 5010 or NCPDP D.0 production receipt for all Medicare crossover claims; and

2. For a limited timeframe (likely 30 days after a supplemental payer cuts over to version 5010 for crossover claims receipt), providers, physicians, and suppliers will need to file the affected claims directly with their patients' supplemental payers.

comparison of HIPAA 4010 & HIPAA 5010

What are the major differences between HIPAA 4010A1 and HIPAA 5010? 

There are changes across all of the transactions, some of which include

                • The ability to support new-use cases brought forward by the industry;

                • Clarification of usage to remove ambiguity;

                • Consistency across transactions;

                • Support of the NPI regulation; and

                • Removal of data content that is no longer used.

Why was it necessary to upgrade to HIPAA 5010?

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 are scheduled to be implemented on Oct. 1, 2013.

What challenges does HIPAA 5010 present to the healthcare industry?

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.

Because of our commitment to guiding our clients through this transition, we will be publishing on www.hipaasimplified.com a summary document of issues and challenges that face each segment of the industry today. 

How can covered entities prepare for the transition to HIPAA 5010?

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.

Because of our commitment to guiding our clients through this transition, we will be publishing on www.hipaasimplified.com a generalized 4010A/5010 gap analysis for each HIPAA standard transaction that we support.

Are there any milestones published by HHS to help organizations meet the compliance dates?

Yes. In the preamble to the Final Rule, HHS has recommended a timeline to help the industry migrate to the new versions of the transactions:

Target Date	Milestone
Jan 2009	Begin Level 1 activities (gap analysis, design, and development)
Jan 2010	Begin internal testing for HIPAA 5010 and NCPDP D.0
Dec 2010	Achieve Level 1 compliance (covered entities have completed internal testing and can send and receive compliant transactions)
Jan 2011	Begin Level 2 testing period activities (external testing with trading partners and move into production; dual 4010A/5010 processing mode) Begin initial ICD-10 compliance activities (gap analysis, design, development, and internal testing)
Jan 1, 2012	5010/D.0 compliance date for all covered entities
Oct 1, 2013	The compliance date for ICD-10-CM and ICD-10-PCS

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.

why hipaa 5010 is required - basic question

5010 Basics

Who is required to make changes for 5010?

All covered entities are included in the 5010 industry-wide mandate. The definition for a covered entity is a health plan, a health care clearinghouse or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Why is the electronic format for health care transactions changing again?

The current format, already eight years old, is unable to meet some important new developments in health care such as supporting the ICD-10 code set and pay for performance. Other changes in the 5010 version will streamline reimbursements. Most of the changes are technical and geared toward improved standardization and uniformity. Many of these can be handled by your vendor and clearinghouse. However, it is important that you understand your own responsibilities in order to become 5010 compliant.

Does 5010 include changes for the CMS-1500 form for professional claims?

The 5010 standards control electronic transactions. The CMS-1500 form is maintained by the National Uniform Claim Committee (NUCC).  NUCC has discussed minor changes to the existing CMS-1500, but no changes have been announced as of yet.  The current form is Version 6.0, which was released July 1, 2010, with usage clarifications and appendices.  No format or data requirements were implemented for 5010.  For more details, you can visit the NUCC website at

http://www.nucc.org/.

HIPAA 5010 - What changes in CMS 1500 - what to do Medical billing company

5010 Tip Of The Week – Billing Provider Address

Did you know, with 5010, the Billing Provider Address you use on claims must be a physical address?  Once 5010 is implemented, you can no longer use PO Box and lock box addresses as a billing provider address.  This rule applies to both professional and institutional claim formats. However, you can still use a PO Box or lock box address as your location for payments and correspondence from payers as long as you report this location as a pay-to address. The pay-to- provider address is only needed if it is different than that of the billing provider. Work with your software vendor to ensure the correct addresses are captured and inserted in the necessary locations on your claim submission.

5010 Tip Of The Week – Nine Digit Zip Codes

Did you know, with 5010, providers must submit a full 9-digit ZIP code when reporting billing provider and service facility locations? An easy way to determine the 4-digit extension to your standard ZIP code is to look it up on the U.S. Postal Service’s ZIP Code Lookup Tool, which can be accessed through the following link http://ZIP4.usps.com/ZIP4/welcome.jsp. Work with your software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses. To help our providers, we will default the last 4 bytes of the billing provider and service facility ZIP codes to ‘9998’ if received as blank to prevent claims from being rejected

5010 Tip Of The Week – Older Claim Formats

Did you know, after the 5010 transition on January 1, Clearing house will continue to support claims sent in older formats, such as ANSI 4010A1, NSF, CMS 1500 and CMS UB-04 print image formats, as well as the new 5010 format?

We know not all clients and practice management software vendors will be ready to use the new 5010 format.  To support our clients and ensure their payments aren’t delayed, we will use our conversion process to translate any format you send us into a 5010-compliant format. In addition, some payers will not be ready to accept the 5010 format. We will identify and track these payers, so we can convert your 5010 files back into the format they need to process your claim.

update on hipaa 5010 and ICD 10

What is going on with 5010 and ICD10… I guess not much

Not too many organizations seem to be unduly concerned about the impending conversion which is now less than two and a half year away for 5010. Or so it seems at least by the actions being taken in the industry. Though I have been hearing a lot about how worried they are regarding the lack of time they might have for changing such a complex network of application portfolio, but not many seem to be taking actions commiserate with their concerns.

We have seen quite a lot of semi-structured exercises taking place, either using internal staff or leveraging high-end consulting organizations but they are primarily limited to very high level analysis of what is going to be impacted. While the initial high level assessment is not a bad idea at all, in my opinion we should be way past that stage by now. A seventy page power-point deck highlighting the twenty core areas that are going to be impacted would have been a good idea in March’2009 but may not be sufficient in October’2009.

Let’s try to see the things in perspective:

1) First of all the mandate date of 1st Jan, 2012 is actually a misnomer. The actual date that one needs to be concerned about is really 1st Jan, 2011. The latter is the date when organizations are supposed to be ready to test their compatibility with their trading partners and the year after that is supposed to be focused more on testing rather than real first-time implementation. So basically all we have is around 15 months and in some cases (such as the Blues) that time is even more restricted because the association’s requirement of being prepared by 1st July, 2010. Barely 9 months away.

2) Second, the tactical approach that most of the organizations are thinking about (i.e., using a step down conversion on the inbound 5010 docs and then propagate the resultant 4010 doc all the way through the downstream applications w/o making any change to them) is not a bad idea at all but definitely has its limitations. The most glaring one being the fact that the shelf life of this solution is not much beyond 1st October, 2013, i.e. when ICD10 mandates take hold. Why I say so is because 4010 can not support ICD10 and if we keep on down-converting the inbound 5010s, the propagated 4010s will need to incorporate the down-converted ICD9 and that defeats the whole purpose of going the ICD10 route. Bye, bye granularity. Bye, bye reduced payouts. Bye, bye increased quality of care. After that it might as well be a mandate being pushed down the throat courtesy CMS.

3) Third, the step-down approach itself is not as simple as some people are assuming it to be. Obviously it is relatively easy to down-convert a 5010 to 4010 (notice the use of word ‘relative’. The conversion is not entirely straight-forward, just simpler than up-conversion) but what happens to the attributes that are new in 5010 and are expected to be used for some decision making process in the downstream applications. By ignoring them during down-conversion (as 4010 will not support them) and hence not using them in the decision making process downstream, is the organization still in compliance with the mandate? Or even if one stores that deleted information in some kind of interim repository, what will be the performance impact on core transaction processes if the applications now have to access the interim repository to get the additional data? In any case, even if one makes simple modification to the core application to fetch the addition data from the interim repository, wouldn’t that call for all sort of regression testing and wouldn’t that defeat the whole concept of not touching the downstream applications? Also, how does one handle the 3rd party apps? The vendors will have either a 4010 compliant app or a 5010 compliant app. They are not going to have an in-between app that will allow the end users to configure an interim repository as the source of additional information while maintaining compliance with 4010 standards.

So, the bottom-line is that even if one is thinking about using the interim tactical approach (that of down-conversion variety), one must not be complacent in terms of time frames. There are many considerations even to implement the interim solution and it is definitely not going to be the final game. So my recommendation is start work on the interim solution immediately and when I say ‘work’, I mean a heck of a lot more than the power points. I mean, identification of required attributes to support 5010 specific mandates in the downstream apps. I mean, identifying the code sets that are going to require the additional data and to design an approach for those code sets to get the new data elements. I mean, designing a fool-proof store-and-forward methodology that can support batch as well as real-time transaction processing and is not a resource hog to eat up all your spare processing time. By the way, does anybody have any spare processing time in any case? I did not think so.

advantages of HIPAA 5010

What are the advantages of HIPAA 5010?

    * Generic enhancements made to all of the HIPAA standards (TR3):
          o Consistent TR3 formats – standardized front matter and appendices
          o Consistent implementation instructions
          o Clearly define situational requirements
          o Approximately 500 industry requested changes
          o Will reduce the need for Companion Guides by providing clearer instructions in the TR3 guides themselves
    * Major Functional Changes
          o Supports ICD-10
                + There is no way to send an ICD-10 diagnosis code in any of the 4010A1 transactions. HIPAA 5010 supports ICD-9 only, ICD-10 only and dual usage of ICD-9 and ICD-10.
          o Clarifies NPI Instructions
                + Always report NPI at the lowest level of specificity
    * Selected Transaction Improvements
          o Eligibility Inquiry/Response 270/271
                + Requires alternate search options to reduce member not found responses
                + Added support for 38 additional Patient Service types on the request
                      # Examples: brand name prescription drug, screening X-ray, lab, burn care
                + Nine categories of benefit information must be reported on the response
                      # Examples: Medical, Dental, Hospital, ER
                + When reporting co-insurance, co-payment and deductible, must also include patient responsibility
                + Overall improvement in the ability to request information and the value of the information returned
          o Health Care Claims (837)
                + Supports ICD-10
                + Clarifies NPI Instructions
                      # Always report NPI at the lowest level of specificity
                + Improves instructions and data content for COB claims
                + Subscriber/patient hierarchy changes
                + Present on admission indicator – Institutional Claims
          o Health Care Request Authorization (278)
                + Significant changes will remove implementation obstacles
                + Medical necessity information added
                + Expect increased use of the transaction once covered entities migrate to 5010
          o New Transactions – 277CA & 999
                + Medicare FFS is replacing proprietary reports with the 277CA – the Claim Acknowledgement transactions
                      # First step to standardizing the payer response to the 837 claim transaction
                      # New reports will need to be written to display the 277CA data
                      # Not a HIPAA mandated transaction, but other payers are following the Medicare lead
                + Medicare FFS is replacing the 997 transaction with the 999
                      # 999 reports syntactical and TR3 guide errors

What is the Timeline for Implementing 5010?


    * Level 1: Internal testing to insure that a covered entity can receive and transmit HIPAA-compliant 5010 transactions
          o CMS advises covered entities to complete Level 1 testing by December 31, 2010
    * Level 2: End-to-end testing with all trading partners
          o CMS mandates Level 2 testing be completed by December 31, 2011
          o 2011 is the year for
                + End-to-end testing with trading partners
                + Conversion to the new standards (Medicare FFS is scheduled to begin accepting 5010 on January 1, 2011)
                + Dual-mode processing (4010 & 5010 depending on trading partner)
          o Full Compliance Date: January 1, 2012
          o What’s next?

ICD-10 Cut-over: October 1, 2013 

time frame for HIPAA 5010 and important dates

5010: Important Changes are Coming

With the implementation of 5010, there will be a few changes in the way you send your electronic claim information. Understanding these changes and how they will affect your practice will prepare you for a smoother transition.  It is recommended that providers start testing for 5010 by January 1, 2011.  This recommendation is for all covered entities (including health care providers, health plans, and health care clearinghouses).


What’s next?

Now is the perfect time to contact your software vendor to determine if they will be providing any upgrades and if they will be testing on your behalf.   There will be practice management system changes that will be required for implementing the 5010 transactions. Depending on the contract with your software vendor, the system upgrades may be included in your current maintenance; however, some vendors may charge for those upgrades.


Questions you may want to ask your software vendor:

    * Can my current system accommodate both the data collection and transaction conduction for 5010?
    * Will you be upgrading my current system to accommodate the 5010 transactions?
    * Will there a charge for the upgrade?
    * When will the upgrades be available?
    * When will the installation to my system be completed?


If your software vendor will not be testing the new format for you, it will be necessary for you to submit test transactions directly to Gateway EDI.  This step will be required to help insure you are able to operate in production mode by the January 1, 2012 compliance date.

HIPPA 5010 and changes in CMS 1500 CLAIM box 33

5010: Important Changes to Provider Information on Claims


With the implementation of 5010, there will be changes required for the way you send your electronic claim information. Understanding these changes and how they will affect your practice will prepare you for a smoother transition.

The Billing Provider Information sent in box 33 of a CMS 1500 form will need to be sent differently for 5010 electronic transactions.   The Billing Provider Information can no longer contain a PO Box or Lock Box and you must send the physical address of the practice.

If you use a PO Box or Lock Box to receive payment, it can still be sent on 5010 electronic transactions.  However, that information will need to be sent in the Pay-to Provider loop.


Here are common questions and answers for handling these changes to the electronic Billing Provider address and Pay-to Provider information:

Will I have to submit a physical address on a claim (street number and name) in the billing provider address?

    * Yes, all payers, including Medicare, will no longer allow a post office box or lock box address for the Billing Provider information (2010AA loop for ANSI claims).
    * Providers must submit a physical address (street number and name) for the billing provider address.
    * The Billing Provider zip code must be nine digits.
    * This rule applies to both professional and institutional claim formats.
    * Providers should work with their software vendors to ensure that the correct addresses are captured and sent in the correct locations for the 5010 implementation deadline.

Can I still have payments sent to a lock box or post office box?

    * Providers that have remittances delivered to a lock box or post office box address must send Pay-To Provider information (2010AB loop for ANSI claims).
    * The Pay-To Provider address is only needed if it is different than that of the Billing Provider.
    * This rule applies to both professional and institutional claim formats.
    * Providers should work with their software vendors to ensure that the post office box or lock box is sent in the correct location for the 5010 implementation deadline.