advantages of HIPAA 5010

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