HIPAA 5010

Q: What are HIPAA 5010 transaction code sets?

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 comply with 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.

Q: What is the compliance date for HIPAA 5010 Transaction and Code Set standards?

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

Q: Does everybody need to upgrade to HIPAA 5010?

You are required to upgrade to HIPAA 5010 standards if you are a covered entity. As a covered entity, you may use the services of clearinghouse to assist in your compliance.

Q: Am I a covered entity?

Yes, you are one of the listed below.

  • Physicians
  • Hospitals
  • Payers
  • Clearinghouses
  • Pharmacies
  • Dentists

Q: How does it affect software vendors and EHR/EMR companies?

Though they do not come under the definition of covered entities, they will have to upgrade their products to comply with HIPAA 5010 and NCPDP D.0 to support their customers more as a business necessity.

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

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

  • Incorporate ability to support advancements in the field of medicine brought forward by the industry
  • Elucidate usage with certainty
  • Consistency across transactions
  • Support of NPI regulation
  • Removal of data content that is no longer used

Q: Why is it necessary to upgrade to HIPAA 5010?

The upgrade to HIPAA 5010 is significant due to multiple reasons:

  • Revealing of unpredicted issues/necessities in the 4010A1 implementation
  • Complying with ICD-10 mandate possible only with HIPAA 5010

Q: What challenges does HIPAA 5010 present to the healthcare industry?

The first and foremost challenge would be a gap analysis which would discern the gaps between the present standard and HIPAA 5010. The other challenges are generally not technical in nature and more to do with addressing business necessities.

Q: 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.

Q: 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