What is version 5010 of the X12 HIPAA Transaction and Code Set Standards?
HIPAA X12 version 5010 and NCPDP version D.0 are new sets of standards that regulate the electronic transmission of specific healthcare transactions, including eligibility, claim status, referrals, claims, and remittances. Covered entities, such as health plans, healthcare clearinghouses, and healthcare providers, are required to conform to HIPAA 5010 standards.
The current transaction standard is the X12 version 4010A1 for eligibility, claims status, referrals, claims, and remittances; similarly, the current standard is NCPDP version 5.1 for pharmacy claims.
Use of the 5010 version of the X12 standards and the NCPDP D.0 standard is required by federal law. The compliance date for use of these standards is January 1, 2012.
Who will need to upgrade to HIPAA 5010?
All covered entities, listed below, are required to upgrade to HIPAA 5010 standards; covered entities may use a clearinghouse assist them with complying with the rules.
Additionally, even though software vendors are not included in the list of covered entities, in order to support their customers they will need to upgrade their products to support HIPAA 5010 and NCDPD D.0 as a business imperative.
What transactions are specified in the HIPAA 5010 standards?
• 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 Acknowledgment
• 820 – Payroll Deducted and Other Group Premium Payment for Insurance Products
• 834 – Benefit Enrollment and Maintenance
• 835 – Health Care Claim Payment/Advice
• 837 – Health Care Claim (Professional , Institutional, and Dental), including coordination of benefits (COB) and subrogation claims
• NCPDP D.0– Pharmacy Claim
Where can the Technical Reports (Implementation Guides) be obtained?
The Technical Reports (TR3 Documents) and their addenda are available for purchase in the X12 Store located at http://store.x12.org/.
These TR3 documents are listed as follows:
• X217 – Health Care Eligibility Benefit Inquiry and Response 270/271
• X212 – Health Care Claim Status Request and Response 276/277
• X215 – Health Care Services – Request for Review and Response 278
• X216 – Health Care Services Notification and Acknowledgment 278
• X218 – Payroll Deducted and Other Group Premium Payment for Insurance Products 820
• X220 – Benefit Enrollment and Maintenance 834
• X221 – Health Care Claim: Payment/Advice 835
• X222 - Health Care Claim: Professional 837
• X223 – Health Care Claim: Institutional 837
• X224 – Health Care Claim: Dental 837