HIPAA (Health Insurance Portability and Accountability Act of 1996) requires that covered entities* comply with its standards when conducting certain electronic health care administrative transactions such as claims, remittance, eligibility, and claims status requests and responses. For EDI (Electronic Data Interchange) transactions, HIPAA requires use of the ANSI (American National Standards Institute) technical content and format specifications. HIPAA also requires use of the ICD (International Classification of Diseases) coding system for medical diagnoses and inpatient procedures.
The former, federally mandated HIPAA-AS standard covered EDI transactions (ANSI 4010/4010A1) have changed, and medical code sets (ICD-9) are changing. These latest mandatory changes represent major revisions to ICD-9 diagnosis and procedure codes for a new ICD tenth revision (ICD-10). Implementation of ANSI 5010, replacing ANSI 4010, is a prerequisite to the change from ICD-9 to ICD-10 codes.
The implementation of 5010 and ICD-10 are intended to improve patient care quality at lower costs, enhance claim processing with fewer errors, improve data reporting and promote increased interoperability across all industry stakeholders. Significant impacts to provider billing and payment processing will be realized across the health care industry if stakeholders fail to collaborate, coordinate and communicate throughout these periods.
The transition period for implementing the new 5010 standards was January 1, 2011 through December 31, 2011. Version 5010 testing was completed by December 31, 2011. Successful conversion to ANSI 5010 was required by January 1, 2012. There is no transition period for the new ICD-10 medical code set standards. The ICD-10 compliance deadline is October 1, 2014.
*Health plans, health care clearinghouses, information trading partners, health information networks, or health care providers who conduct HIPAA-standard transactions.
2009 - January 16, 2009 New 5010 Rule
2010 - December 31, 2010 Level 1 Compliance
2011 - December 31, 2011 Level 2 Compliance (Testing should be complete)
2012 - January 1, 2012 5010 Compliance
2014 - October 1, 2014 ICD-10 Compliance
Frequently Asked Questions
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.
3. Identify changes to data report requirements. Data reporting requirements for Version 5010 transactions vary from the current transactions. These changes could require the collection of additional data or reporting data in a different format. For example, with Version 5010, the billing provider address can no longer be reported as a P.O. Box or lockbox address. Some questions to ask include:
- Can we identify the data reporting changes for the transactions we use?
- Can we find the resources to assist us in identifying the data reporting changes and if so, what is the cost of the resources?
- Can this new data be stored in our current system or will it require a system upgrade to store it?
- Will we need to purchase additional hardware for the new reporting requirements?
4. Identify possible modifications to current workflow and business processes. Once data reporting changes have been identified, workflow modifications may be necessary. Some questions to consider include:
- What workflow processes do we need to change or add to capture the new data?
- What additional costs will we incur from new data collection methods?
- What will be the cost of modifying our workflow processes?
5. Identify staff training needs. Training staff ensures that transactions continue to be submitted, received, interpreted, and responded to correctly using Version 5010 transactions. Some questions to consider include:
- Who should be trained on the transaction changes?
- How long will it take to train staff on the changes?
- What resources ware needed for training the staff?
- What is the cost of the training resources?
6. Test with your trading partner(s). The final step for a provider before going “live” with Version 5010 transactions will be to complete testing with your trading partner(s) – the organizations providers use to exchange transactions. Some questions to consider include:
- Which transactions should we test?
- When should we begin to test?
- Which trading partners do we test with?
- Do we use test data or live data during testing?
Note: Testing with all of your trading partners may not be possible if you have hundreds of them. If you find it is not possible to test with all of them, you will definitely want to test with those that make up the largest share or those who handle your transactions with the largest revenue. Schedule times with them to test. Testing is the only way to be sure you’ll experience a smooth transition to the 5010 mandate.
What is Florida Blue doing to prepare for ANSI 5010 compliance?
Florida Blue has mitigated all of its internal systems to accept, process and send 5010 compliant electronic transactions.
As of May 2011, Florida Blue has engaged our external trading partners to “test” 5010 capabilities with us. We are currently engaged in a 5010 Production Validation Process (PVP). The PVP process is designed to provide a controlled production verification and validation process whereby 5010 compliance adherence and business rules editing are completed prior to full production implementation.
Additionally, Florida Blue is conducting weekly interactive teleconferences with its providers and electronic trading partners. The teleconference, HIPAA 5010 Open Line Friday is offered to bring participants up-to-date on Florida Blue’s HIPAA 5010 readiness, transition and overall status.
- ANSI 4010 and 5010 Companion Documents
- Center for Medicare & Medicaid Services
- ANSI X12N Implementation Guides for 4010A1 and 5010A1 from Washington Publishing Company
- 5010 federal regulation information, education and news from the Centers for Medicare & Medicaid Services
- Additional Version 5010 resources from CMS
- CMS ICD-10 Website
- Workgroup for Electronice Data Interchange
- American Medical Association
- AHIMA ICD-10 Website
- Availity 5010
FB PRV COMP 003 NF 082015