HIPAA 5010 Background

Click these links to learn about about HIPAA 5010 background:

 

Click these links to learn about about key areas of change in HIPAA 5010:

 

HIPAA 5010 Background

What is HIPAA 5010?

HIPAA 5010 is a new electronic file formatting and content standard that will be adopted by the health insurance industry and was mandated by the US Department of Health & Human Services (HHS).

The new 5010 standards are required for the administrative and financial electronic data exchange between health care providers, health plans, and covered entities for patient care services.

The 5010 standards are the foundation for supporting future ICD-10 code sets and will replace 4010-A1 standards previously mandated under HIPAA.

How do insurers and providers achieve 5010 compliance?

Providers achieve 5010 compliance by upgrading their billing systems and by producing and receiving updated 5010 claims and remittance transactions.

Providers who submit claims electronically today must continue to submit electronic claims in 5010 claims format starting January 1, 2012.

How do providers know if they are submitting HIPAA 5010 compliant claims to Community Health Plan?

They will appear in and be processed by the Plan's claim processing system on January 1 and thereafter.

Providers should ask their billing manager, billing service, or billing software vendor for details about what has been done to insure compliance.

Electronic claims rejections. Providers (or their billing services or billing/practice management software) who have not upgraded systems to generate and receive HIPAA 5010 compliant claims will be rejected by clearinghouses on January 1, unless special arrangements have been made with the clearinghouse for continuing to accept 4010 claims.

Key areas of change

Characters allowed and field sizes have changed to accommodate new codes and to make identification more specific. For instance, there are changes in how NPI, provider address, and diagnosis codes are entered.

The following transactions are most impacted. These changes will not impact the end user as much as the actual file because the format in which data is sent will be modified.

  • ELIGIBILITY (Transaction ID: 270/271). Clarifies dependent and subscriber relationship records.
  • ENROLLMENT (Transaction ID: 834). Improves privacy protections and adds information such as enrollment subtotals and coverage reasons.
  • CLAIMS (Transaction ID: 837 P/I). Separates diagnosis code reporting, clarifies NPI usage, simplifies COB requirements.
  • REFERRALS/AUTHS (Transaction ID: 278). Provides specific information about conditions, supports and expands authorization exchanges.

 

A more complete list of major differences between 4010 and 5010 includes:

  • Support for ICD-10 coding
  • Support for new use cases, such as:
    • Medicaid subrogation
    • Ambulance
    • Condition codes in 837 (professional, institutional, and dental claims including coordination of benefits and subrogation)
    • Anesthesia
  • Clarification of ambiguous usage
  • Consistency across transactions
  • Support for NPI
  • Removal of unused data content

 

Formats to be changed include:

  • Authorization transmittal (278)
  • Claims (837-I, 837-P, 837-I COB, 837-P COB, and NCPDP)
  • Claim status inquiry and response (276 and 277)
  • Eligibility inquiry and response (270 and 271)
  • Remittance advice (835)

 

Explore HIPAA 5010 resources.

For more information, contact:

Les Demme, Program Director
Email Leslie.Demme@chpw.org
Phone 206-515-7997