Health Policy Institute (HPI) Update

HIPAA
5010 Requirements

The Health Insurance Portability and Accountability Act (HIPAA) requires the adoption of specific standards for electronic health care transactions, e.g., claims, eligibility inquiries, claims status requests and responses. The current version is 4010A1, but federal regulation mandates that it be replaced with the new 5010 version by January 1, 2012. At that time, all electronic transactions you or your vendors send to Blue Cross Blue Shield of North Dakota (BCBSND) and other payers must use HIPAA 5010.

This deadline may appear to be distant, but significant work must be accomplished to prepare for this mandatory conversion. At a high level, you must meet three objectives:

Identify the differences between 4010A1 and 5010, and determine what applications, systems and operating protocols will need to change. (This should be complete or under way now.)
Implement changes to systems and protocols, and test the changes (This should be completed by the end of 2010.)
Schedule and complete tests with external partners and transition with them to the 5010 transactions by the compliance date. (You are encouraged to start this as early as January 1, 2011.)
BCBSND's preparations for the implementation of 5010 are under way. If you have questions about 5010, please contact Provider Service at 800-368-2312.

Frequently Asked Questions

What is HIPAA 5010?
The Health Insurance Portability and Accountability Act (HIPAA) is the federal regulation that requires the use of standard X12 transactions to report and inquire about health care services. If you use electronic transactions, the current version is 4010A1. The new version of the standards is called 5010.

How is 5010 different from 4010A1?
The new 5010 version is superior to 4010A1. The documentation explaining how to report your claims and inquiries is easier to understand in the new version. Version 5010 fully supports the reporting of National Provider Identifiers (NPI) and the new ICD-10 codes. Additionally, the version is more streamlined, because content that wasn't used in 4010A1 has been removed in the 5010 version.

Does 5010 apply to me?
HIPAA 5010 applies to you if you currently use version 4010A1 of the standard electronic transactions or if you want to begin electronically reporting or (inquiring about) health care transactions.

When must version 5010 be in place?
HIPAA 5010 must be implemented by January 1, 2012, but given the complexities of the conversion, you must begin preparing for the transition now. After January 1, 2012, version 4010A1 will no longer be valid.

Can I still use your web portal to file claims after January 1, 2012?
Yes, the federal mandate allows us to continue making BCBSND's web portal available to you even after the compliance date. But, you will only be able to send electronic transactions or inquiries to BCBSND if you are using version 5010.

How do I begin?
Consider opening a dialogue with your facility or practice management vendor and clearinghouse. Prepare for the discussion by reviewing your contracts to determine what terms apply when major, federally mandated data set changes must be made. Then, ask your vendors what preparations they are making to support your 5010 business requirements in time for the January 1, 2012, compliance date. Ask for details such as a project plan and timeline.

What if my vendor hasn't started to plan for 5010?
One approach would be to express your concern and follow up with them periodically until they are able to offer assurances that you find acceptable. You also may need to develop a backup plan for meeting the compliance date.

Currently, I file claims on paper. Will I need to start sending 5010 electronic transactions on January 1, 2012?
Electronic transactions are a very efficient way to file claims and make inquiries. BCBSND encourages you to consider this approach. However, we will not require that you switch to electronic transactions if you use paper today.

Will there be changes to the paper claims (i.e., UB-04, CMS-1500) because of 5010?
No, the most recent versions of the paper claims accommodate the relevant data reported in 5010.

Can we continue to use CMS-1500 paper claims after the compliance date for 5010?
Yes, you may use CMS-1500 paper claims after January 1, 2012. The CMS-1500 claim form was updated in 2007 and the changes made were consistent with the changes in HIPAA version 5010.

I am currently submitting paper claims, but would like to begin submitting them electronically prior to January 1, 2012. In which version should I invest?
BCBSND is planning to be able to receive all 5010 transactions by July 1, 2011. If you use PC-ACE, the free claims submission solution available from BCBSND, you will be able to submit using 4010 today and 5010 when appropriate.

What will happen if my vendor is not ready to send 5010 transactions by January 1, 2012?

Non-compliant transactions received after January 1, 2012 will be rejected as directed by CMS.

Where can I find additional information about 5010?
The Centers for Medicare and Medicaid Services (CMS) has posted an MLN Matters article titled "An Introductory Overview of the HIPAA 5010" that you might find useful. This article offers a helpful summary, especially for those who are not involved directly in HIPAA 5010 projects.

ICD-10-CM - Final Rule Issued
On January 16, 2009, The Centers for Medicare & Medicaid Services (CMS) issued the final rule to modify the standard code sets for coding diagnoses and inpatient hospital procedures by adopting the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for diagnosis coding and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure coding. These new code sets will replace the current three volumes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The entire rule can be found in the Federal Register/Vol.74, No. 11/Friday,
January 16, 2009/Rules and Regulations.

The timetable for implementation of ICD-10 is October 1, 2013, for all covered entities. This corresponds to the effective date of annual Medicare inpatient updates. Before implementation of ICD-10, Version 5010/D.0 of the HIPAA Transactions Standards must also be implemented. The implementation date for Version 5010 is January 1, 2012.

Additional information related to ICD-10-CM can be found at the American Hospital Association ICD-10 Resource Center .

Blue Cross Blue Shield of North Dakota has formed a multi-departmental corporate project to begin preliminary work related to system changes required for Version 5010 and the ICD-10 conversion. As timelines are established, future articles will provide updates on readiness for ICD-10 and other necessary information for the provider community.