5010 Resource Center

This site’s objective is to communicate to providers, clearinghouses, and vendors the information needed to convert from the HIPAA 4010A1 version of transactions to the 5010 version. At this time all entities that send claims to Arkansas BlueCross and BlueShield must be using the X12 5010 and NCPDP Version D.0 standards by January 1, 2012.

Visit the 5010 resource center often in 2011 for the latest information and timelines.

Background

The Health Insurance Portability and Accountability Act (HIPAA) requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards that covered entities (health plans, health care clearinghouses, and certain health care providers) must use when they electronically conduct certain health care administrative transactions, such as claims, remittance, eligibility, claims status requests and responses, and others. The Transactions and Code Sets final rule published on Aug. 17, 2000, adopted standards for the statutorily identified transactions, some of which were modified in a subsequent final rule published on Feb. 20, 2003.

These current versions of the standards (the Accredited Standards Committee X12 Version 4010/4010A1 for health care transactions, and the NCPDP Version 5.1 for pharmacy transactions) are widely recognized as lacking certain functionality that the health care industry needs. On January 16, 2009, HHS announced a final rule that replaces the current Version 4010/4010A and NCPDP Version 5.1 with Version 5010 and Version D.0, respectively.

Impact To You

The implementation of HIPAA 5010 presents substantial changes in the content of the data that you submit with your claims as well as the data available to you in response to your electronic inquiries. The implementation will require changes to the software, systems, and perhaps procedures that you use for billing Medicare and other payers. So it is extremely important that you are aware of these HIPAA changes and plan for their implementation.

What You Need To Know

The Administrative Simplification Compliance Act (ASCA) requires the use of electronic claims (except for certain rare exceptions) in order for providers to receive payment. Therefore, effective January 1, 2012, you must be ready to submit your claims electronically using the X12 Version 5010 and NCPDP Version D.0 standards. This also is a prerequisite for implementing the new ICD-10 codes. Arkansas BlueCross and BlueShield will provide additional information to assist you and keep you apprised of progress on our implementation of HIPAA 5010 through a variety of communication vehicles. Remember that the HIPAA standards, including the X12 Version 5010 and Version D.0 standards, are national standards and apply to your transactions with all payers. While the new claim format accommodates the ICD-10 codes, ICD-10 codes will not be accepted as part of the 5010 project.

What You Need To Do

In preparing for the implementation of these new X12 and NCPDP standards, providers should also consider the requirements for implementing the ICD-10 code set as well. You are encouraged to prepare for the implementation of these standards or speak with your billing vendor, software vendor, or clearinghouse to inquire about their readiness plans for these standards.

5010 Testing


Other helpful links for providers:

http://www.wpc-edi.com/content/view/711/401/ - Washington Publishing Company Health Care Code Sets
http://www.cms.gov/versions5010andd0/ - Central Version 005010 and D.0 webpage on CMS website