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HIPAA 5010 Rule explained

March 21, 2012

HIPAA 5010 stop signHIPAA X12 standard – version 5010 is a new standard that regulates the electronic transmission of specific healthcare transactions.

Covered entities, such as healthplans, health care clearinghouses, and health care providers, are required to conform to HIPAA 5010 standards. The compliance date for use of these standards is January 1, 2012. It is necessary to implement the new standard to prepare for the transition to ICD-10-CM and ICD-10-PCS. The compliance date for ICD-10 is  October 1, 2014.

As a provider should I care?

HIPAA 5010 can be understood as an upgrade on the existing form of HIPAA rather than a significant change in the way HIPAA-defined benchmarks have been defined for processing transactions in the healthcare industry. The changes put forth as a part of HIPAA 5010 were being anticipated for some time since the existing standards of HIPAA were beginning to seem a bit outdated. HIPAA 5010 has been created in such manner that the forthcoming changes in the revised medical billing/coding data of ICD- 

10-CM & ICD-10-PCS will be accommodated by all covered entities in a better manner. These changes in the coding systems are scheduled to be made effective from October 1, 2014 and thus, adoption of HIPAA 5010 will mean that all covered entities and their business associates have sufficient time and proper understanding of the altered coding systems. However, this doesn’t mean that HIPAA 5010 doesn’t present any challenges to the US healthcare industry.

Whats the difference between old HIPAA 4010A1 and new HIPAA 5010?

There are some major differences between HIPAA 5010 Rule and the existing, HIPAA 4010A1 standards. As a result, the entire process of upgrading to HIPAA 5010 could be a bit time consuming. However, this slight deterrent is largely negated by the fact that the adoption of HIPAA 5010 will improve the quality of transactions in many ways. The most notable advantages would be the removal of ambiguities in the existing healthcare information processing systems, ensuring more consistency in healthcare transactions. This will also help to graduate towards adopting NPI regulations in a more comprehensive manner and easier elimination of patient data that has no relevance. Covered entities or business entities in the US healthcare industry shouldn’t feel threatened by the introduction of HIPAA 5010 since it doesn’t put forth a financial stress on their operations. These entities merely need to review their existing systems and that of their business partners and understand how HIPAA 5010-defined standards can be adopted, i.e. ensuring HIPAA 5010 compliance in the most undemanding manner is possible.

What do I need to do to prepare for ANSI 5010 compliance? 

1. Speak with your current practice management system vendor. Software vendors are not covered “entities” and therefore, not responsible for compliance. However, your compliance depends on your vendor’s implementation of compliant products. 

Ask your vendor(s):

    • Will you upgrade your current system to accommodate Versions 5010 transactions?
    • Will the upgrade include acknowledgement of transactions 277CA and 999?
    • Will the upgrade include a “readable” error report produced from 277CA and 999 transactions?
    • When will you be capable of supporting Version 5010 transactions?
    • Will you be able to support both Version 4010A1 and 5010 transactions concurrently?
    • When will the current system accommodate both the data collection and transactions conduction for Version 5010?
    • When will the upgrades be available and will there be a charge?
    • When will the software installation to the systems be completed? Before January 1, 2012?
    • Will there be adequate lead time to test the new software prior to the January 1, 2012 compliance date?

Note: If your current system cannot handle 5010 transactions or your vendor isn’t planning on updating their system to accommodate 5010 transactions, you may have to purchase new software. If so, you’ll need to set aside enough time to research different programs and an appropriate budget for paying for the cost of new software or a system.

It is very important that your vendor completes the installation of system upgrades in your practice early enough to allow to test the transaction process with your electronic trading partners (billing service, clearinghouse, health plan, etc.). You will also want to plan appropriately in advance for training your staff.

2. Speak with your clearinghouses, billing services and health insurance payers. You’ll want to ask them:

    • Are you planning to upgrade your systems to accommodate Version 5010 transactions?
    • When will you complete the upgrades?
    • Will you change your fees for Versions 5010 transactions?
    • Will we need to register in order to conduct 5010 transactions? How?
    • When can we send you our test transactions to ensure the system works accurately?

Note: Based on the responses to the above questions, you will know if your clearinghouses and billing service can continue to support your business. This information will help you plan budget needs and help develop a timeframe for testing and implementing. It is essential that you contact all of your payers, billing services and clearinghouses to ensure your transition to 5010 will run without payment interruptions. 

M-Scribe uses 5010 complaint web based practice managment software which works with windows and mac operating systems.

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