What are the advantages of HIPAA 5010?
* Generic enhancements made to all of the HIPAA standards (TR3):
o Consistent TR3 formats – standardized front matter and appendices
o Consistent implementation instructions
o Clearly define situational requirements
o Approximately 500 industry requested changes
o Will reduce the need for Companion Guides by providing clearer instructions in the TR3 guides themselves
* Major Functional Changes
o Supports ICD-10
+ There is no way to send an ICD-10 diagnosis code in any of the 4010A1 transactions. HIPAA 5010 supports ICD-9 only, ICD-10 only and dual usage of ICD-9 and ICD-10.
o Clarifies NPI Instructions
+ Always report NPI at the lowest level of specificity
* Selected Transaction Improvements
o Eligibility Inquiry/Response 270/271
+ Requires alternate search options to reduce member not found responses
+ Added support for 38 additional Patient Service types on the request
# Examples: brand name prescription drug, screening X-ray, lab, burn care
+ Nine categories of benefit information must be reported on the response
# Examples: Medical, Dental, Hospital, ER
+ When reporting co-insurance, co-payment and deductible, must also include patient responsibility
+ Overall improvement in the ability to request information and the value of the information returned
o Health Care Claims (837)
+ Supports ICD-10
+ Clarifies NPI Instructions
# Always report NPI at the lowest level of specificity
+ Improves instructions and data content for COB claims
+ Subscriber/patient hierarchy changes
+ Present on admission indicator – Institutional Claims
o Health Care Request Authorization (278)
+ Significant changes will remove implementation obstacles
+ Medical necessity information added
+ Expect increased use of the transaction once covered entities migrate to 5010
o New Transactions – 277CA & 999
+ Medicare FFS is replacing proprietary reports with the 277CA – the Claim Acknowledgement transactions
# First step to standardizing the payer response to the 837 claim transaction
# New reports will need to be written to display the 277CA data
# Not a HIPAA mandated transaction, but other payers are following the Medicare lead
+ Medicare FFS is replacing the 997 transaction with the 999
# 999 reports syntactical and TR3 guide errors
What is the Timeline for Implementing 5010?
* Level 1: Internal testing to insure that a covered entity can receive and transmit HIPAA-compliant 5010 transactions
o CMS advises covered entities to complete Level 1 testing by December 31, 2010
* Level 2: End-to-end testing with all trading partners
o CMS mandates Level 2 testing be completed by December 31, 2011
o 2011 is the year for
+ End-to-end testing with trading partners
+ Conversion to the new standards (Medicare FFS is scheduled to begin accepting 5010 on January 1, 2011)
+ Dual-mode processing (4010 & 5010 depending on trading partner)
o Full Compliance Date: January 1, 2012
o What’s next?
ICD-10 Cut-over: October 1, 2013
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