5010 News Alerts

The Centers for Medicare and Medicaid Services (CMS) has adopted a new electronic transaction standard for the exchange of electronic health care transactions. The current standard required by the Health Insurance Portability and Accountability Act (HIPAA), 4010, is being replaced by a new standard, Accredited Standards Committee (ASC) X12 Version 5010 (5010), effective January 1, 2012.

HIPAA 5010 End-to-End Certification Testing Update

HIPAA 5010 End-to-End Certification Testing is now available. Instructions for completing the End-to-End Certification Testing process are in the 5010 End-to-End Certification Testing News Update. Providers should begin testing their claims as soon as possible to obtain certification.

Providers who have not completed syntactical testing for HIPAA 5010 should refer to the section Getting Started with 5010 Testing below.

NOTE: The End-to-End Certification Testing instructions above do not pertain to Pharmacy Providers. Pharmacy Providers will receive separate instructions regarding D.0 transaction testing.

Getting Started with 5010 Testing

The Alaska Medicaid Program is supporting early provider testing of 5010 X12 transactions through the use of a free testing website sponsored by Edifecs, Inc. Edifecs allows providers to validate that their 5010 transactions comply with the minimum X12 standards for 5010 transaction data format.

This early testing opportunity will NOT validate Alaska-specific X12 data content requirements. Testing for end-to-end compliance with specific State data requirements will occur later and will be communicated at the appropriate time.

Providers may request a User ID and Password to access the testing website, either by email at AKHIPAASupport@acs-inc.com,or by calling the toll free number (855) 226-9391. Once an ID and Password have been assigned, providers may log into the testing website, https://sites.edifecs.com/?medicaidalaska, and follow the instructions for submitting 5010 test transactions. Immediate feedback will be received regarding any format errors that are detected. The transactions can then be corrected and retested until they are error free.

For questions about early 5010 transaction testing on the Edifecs test site, please contact us using the email address or toll free telephone number listed above.

The Transition from 4010 to 5010

The original 4010 standard was adopted in 2000, and since then it has undergone several revisions to address shortcomings.

In 2009, the Centers for Medicare and Medicaid Services (CMS) adopted a final rule that mandates all covered entities adopt the medical coding standard called ICD-10.  The ICD-10 standard includes a built-in requirement that covered entities must upgrade all electronic transactions to the new data standard, 5010.

The source for transaction format specifications is the Technical Reports Type 3, also known as TR3s. The TR3s replace the Implementation Guides that currently define electronic transaction formats. Each transaction type has its own TR3. The TR3 guidelines are available from Washington Publishing Company.

5010 Improvements

The 5010 standard introduces several improvements to the 4010 data structure, including:

• Standards for business information related to transactions such as provider name and address
• Introduction of future clinical data reporting standards for International Classification of Diseases, Tenth Revision – Clinical Modification (ICD-10-CM) diagnosis codes and International Classification of Diseases, Tenth Revision – Procedure Classification System (ICD-10-PCS) procedure codes
• Improved data for principal diagnosis, including admitting diagnosis, external cause of injury and patient reason for visit codes
• Collection of statistical data such as illness mortality rates, clinical reasons for care and length of hospital stays

In addition to these increased levels of detail, 5010 also fulfils certain business needs that 4010 did not address, such as “present on admission” conditions for institutional claims.

5010 Impact on Pharmacy Claims

The 5010 standard also impacts pharmacy claims. The new standard, National Council for Prescription Drug Programs (NCPDP) D.0, known as D.0, includes improvements that focus on Medicare, but also impact Medicaid. These include better identification of patient responsibility, stages of benefits, and gaps in coverage on secondary claims as well as facilitation of claims that involve compounded drugs.