HIPAA 5010 is the next step towards implementing Administrative Simplification between Healthcare Covered Entities. HIPAA 5010 paves the way for further standardization providing Trading Partners better communication and more efficient, less expensive business processes. In January 2009, CMS mandated conversion to HIPAA version 5010 by January 1, 2012. Generic enhancements made to all of the HIPAA standards (TR3) include:
Consistent TR3 formats – standardized front matter and appendices
Consistent implementation instructions
Clearly define situational requirements
Addresses approximately 500 industry requested changes
Will reduce the need for Companion Guides by providing clearer instructions in the TR3 guides themselves
Major functional changes brought about by HIPAA 5010 include:
HIPAA 5010 supports ICD-9 only, ICD-10 only and dual usage of ICD-9 and ICD-10
Clarifies National Provider ID (NPI) Instructions and states which NPI should be sent.
The instructions state that a provider always reports NPI at the lowest level of specificity.
The major benefits of HIPAA 5010 include:
• 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
• Nine categories of benefit information must be reported on the response
• 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
• 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
• Significant changes will remove implementation obstacles
• Medical necessity information added
• Expect increased use of the transaction once covered entities migrate to 5010
