HIPAA 5010 - What It Is and How It Will Affect You

This is a basic breakdown of the HIPAA 5010. There are much more technical requirements, information and explanations.

Well, most of you should know what 5010 is and how it will affect you. If you don't you must have at least heard about it. It seems that all insurance carrier publications are overflowing with confusing information on this transition and the quickly approaching deadline. So we are going to try to break it down for those who still don't really understand what it is and if they need to do something.

First - what is it? HIPAA 5010 is a federal mandate that requires health plans, clearinghouses, and providers to use new standards in electronic transactions including claims, remittance, eligibility, and claims status requests and responses. HIPAA 5010 is an upgrade from the current mandate, or HIPAA 4010A. The new mandate is supposed to increase transaction uniformity and streamline reimbursement transactions.

The deadline for this new mandate is January 1, 2012. All affected organizations and providers should have long ago begun at the very least testing if they are not already compliant with the 5010 mandate or as Ingenix says "As the deadline approaches, affected health care organizations need to upgrade and test their claims management systems to accommodate 5010 and prevent operational disruptions." This means that if your current software is not compliant with 5010 then you will need to upgrade. And before we reach the deadline you will need to have tested your system to make sure it is compliant. Not doing so before the deadline may result in "operational disruptions" or in terms the provider will understand, mess up the accounts receivable.

So how do you know if you need to do something to prepare for HIPAA 5010? Well, if you submit all claims on paper and you don't receive any ERA's then you don't need to do anything. HIPAA 5010 is for electronic transactions only. That was pretty easy.

If you do submit claims electronically or do receive ERA's then you need to see if your system is compliant. Most people submit claims thru a clearinghouse. If you use a clearinghouse then you need to check with your clearinghouse to make sure they are compliant or to see where they are in the testing phase. Most of the major clearinghouses are prepared. You should also make sure that the practice management system that you use to create your electronic batches is going to be compliant as well. Make sure there is nothing that you need to do on your end.

If you receive your ERA's thru a clearinghouse, again you just need to make sure that they are compliant or are on track to be compliant. If you receive any ERA's directly from the insurance carriers you should check with them to see if there is anything that you need to do on your end.

Some providers or billing services submit claims using their own software as a clearinghouse. If you are one of these people you will need to make sure your software is updated by checking with your vendor.