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HIPAA 5010 transaction standards

In support of L&I’s continuing commitment to HIPAA administration simplification and standards for EDI of health care data, the department will update its systems to meet the new standards for electronic transactions in the 5010 ASC X12 version format for Health Care Professional and Institutional 837 billing, and NCPDP version D.0 for pharmacy prescription billing.

The new standards will:

• Increase transaction uniformity.
• Support pay-for-performance.
• Streamline reimbursement transactions.
• Support ICD-10-CM codification.

Impact of 5010

The implementation of 5010 means substantial changes in the data that you submit with your claims as well as the data you receive electronically. The implementation of 5010 may require changes to the software, systems, and procedures that you use for billing payers.

5010 Implementation Schedule

L&I’s Provider Express Billing (PEB) and Medical Information Payment System (MIPS) will be compliant for processing both ANSI 5010 and the ICD-10-CM code sets according to the timelines established by the HHS.

• March - May, 2011 - L&I internal testing for 5010 transactions
• May - June, 2011 – Begin limited external testing with specific trading partners ready to test 5010 transactions.
• July, 2011 - Begin external testing with all trading partners ready to test 5010 transactions
• January 1, 2012 compliance date for version 5010 and NCPDP version D.0
• October 1, 2014 compliance date for ICD-10-CM.
• Note on ICD-10-CM – The implementation of 5010 is a prerequisite for implementing the new ICD-10 codes. While the new claim format accommodates the ICD-10 codes, ICD-10 codes will not be accepted as part of the 5010 project.

What You Need to Know

Providers submitting electronic billing through a clearinghouse will need to contact their software vendor and ensure that billing data sent to their clearinghouse complies with 5010 standards and payer requirements.  The clearinghouse will be responsible for testing 5010 transactions with the department and communicating submission results back to the provider.

Direct submitters will need to review their systems to meet 5010 standards and test their 5010 submissions and responses directly with L&I.

5010 HIPAA Companion Guide

This guide details the HIPAA ASC X12N 005010 format structure for EDI and provides information regarding electronic billing to the department via Provider Express Billing (PEB).

5010 Testing

Clearinghouses and Direct Submitters will be required to successfully complete testing of 5010 file submissions and transaction processing prior to authorization for production EDI submissions.

During testing, we will continue to support the current version 4010A1 Professional and Institutional 837 submissions in Production as well as our proprietary format.

L&I’s systems will support testing of the following 5010 transactions:

• Submissions
  • Health Care Claim: Professional 837 (005010X222A1)
  • Health Care Claim: Institutional 837 (005010X223A2)
• Responses
  • Interchange Acknowledgment TA1
  • Implementation Acknowledgment 999 (005010X230A1)
  • Application Reporting for Insurance 824 (004010X161)
  • Application Reporting for Insurance 824 (005010X186) - to be developed
• Notices
  • Health Care Claim Payment/Advice 835 (005010X221A1)
  • Health Care Claim Notification 277 (005010X214A1)

Please contact the Electronic Billing Unit with any questions regarding 5010 changes or testing. If you are ready to begin testing contact us for scheduling and coordination of your test submissions.

5010 Support
Electronic Billing Unit
Email: ebulni@lni.wa.gov
Phone: 360-902-6511