This site’s objective is to communicate to providers, clearinghouses, and vendors
the information needed to convert from the HIPAA 4010A1 version of transactions
to the 5010 version. At this time all entities that send claims to Arkansas Blue Cross
and Blue Shield must be using the X12 5010 and NCPDP Version D.0 standards by January
1, 2012.
Background
The Health Insurance Portability and Accountability Act (HIPAA) requires the Secretary
of the Department of Health and Human Services (HHS) to adopt standards that covered
entities (health plans, health care clearinghouses, and certain health care providers)
must use when they electronically conduct certain health care administrative transactions,
such as claims, remittance, eligibility, claims status requests and responses, and
others. The Transactions and Code Sets final rule published on Aug. 17, 2000, adopted
standards for the statutorily identified transactions, some of which were modified
in a subsequent final rule published on Feb. 20, 2003.
These current versions of the standards (the Accredited Standards Committee X12
Version 4010/4010A1 for health care transactions, and the NCPDP Version 5.1 for
pharmacy transactions) are widely recognized as lacking certain functionality that
the health care industry needs. On January 16, 2009, HHS announced a final rule
that replaces the current Version 4010/4010A and NCPDP Version 5.1 with Version
5010 and Version D.0, respectively.
Impact To You
The implementation of HIPAA 5010 presents substantial changes in the content of
the data that you submit with your claims as well as the data available to you in
response to your electronic inquiries. The implementation will require changes to
the software, systems, and perhaps procedures that you use for billing Medicare
and other payers. So it is extremely important that you are aware of these HIPAA
changes and plan for their implementation.
What You Need To Know
The Administrative Simplification Compliance Act (ASCA) requires the use of electronic
claims (except for certain rare exceptions) in order for providers to receive payment.
Therefore, effective January 1, 2012, you must be ready to submit your claims electronically
using the X12 Version 5010 and NCPDP Version D.0 standards. This also is a prerequisite
for implementing the new ICD-10 codes. Arkansas Blue Cross will provide additional information to assist you and keep you apprised of progress
on our implementation of HIPAA 5010 through a variety of communication vehicles.
Remember that the HIPAA standards, including the X12 Version 5010 and Version D.0
standards, are national standards and apply to your transactions with all payers.
While the new claim format accommodates the ICD-10 codes, ICD-10 codes will not
be accepted as part of the 5010 project.
5010 Testing
Other helpful links for providers:
Washington Publishing Company Health Care Code Sets
Central Version 005010 and D.0 webpage on CMS website