HIPAA: 5010 Transactions

• 5010 Resource Center

Keystone Mercy Health Plan recognizes that providers will be greatly impacted by the changes that will be required to become compliant with this federally mandated rule. We will communicate with you regularly to disseminate information, answer questions, address issues and concerns in this publication, faxes, e-mail, letters, as well as provide updated information on this dedicated HIPAA 5010 page.

Getting Ready for the Transition to HIPAA Version 5010 Transactions

The U.S. Department of Health and Human Services (HHS) as required by HIPAA has adopted standards for all covered entities to use when conducting certain electronic health care administrative transactions. Accordingly, the mandatory compliance date for Version 5010 for all covered entities is January 1, 2012.

What does this mean?

The current transaction standard is X12 Version 4010A. This version is outdated and will not facilitate the implementation of ICD-10, which is anticipated for 2013. Version 5010 will include improvements to allow the use of the expanded ICD-10 sets.

• 270/271 - Health Care Eligibility Benefit Inquiry and Response
• 276/277 - Health Care Claim Status Request and Response
• 278 - Health Care Services Request for Review and Response; Health Care Services Notification and Acknowledgement
• 835 - Health Care Claim Payment/Advice 
• 837 - Health Care Claims (Professional, Institutional and Dental, including Coordination of Benefits (COB) and Subrogation Claims)
• NCPDP 5.1 (Upgrading to D.0) - Pharmacy Claims

LEVEL ONE
December 31, 2010

• Have completed all internal activities and testing
• Be capable of creating and receiving compliant transactions

January 1, 2011

• Be ready to conduct test transactions with trading partners

LEVEL TWO
January 1, 2012

• Accept and submit only 5010

What to Do Now?

Contact your vendor and ask:

• What are their plans and timelines for implementing Level 1 testing
• Do you need to purchase or install software upgrades?