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Version 5010

Version 5010. New Health Care Electronic Transactions Standards. HIPAA 101.

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Version 5010

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  1. Version 5010 New Health Care Electronic Transactions Standards

  2. HIPAA 101 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that 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 electronically conducting certain health care administrative transactions, such as claims, remittance, eligibility, and claims status requests and responses.

  3. HIPAA HIPAA was enacted into law in 1996. The law contained a section: Administrative Simplification - that included requirements for Electronic transactions and Code set standards, Privacy, Security, and National identifiers. HIPAA was designed to streamline the administration of health care with uniformity. Today we submit electronic transactions on Version 4010 or 4010A1. This version has become outdated and Version 5010 became a regulation on January 16, 2009

  4. FAQ • What is version 5010 of the X12 HIPAA Transaction and Code Set Standards? • HIPAA X12 version 5010 is an updated set of standards that regulate the electronic transmission of specific healthcare transactions to include eligibility, claim status, referrals, claims, and remittances. Some changes include clarification of usage to remove ambiguity; consistency across transactions; support of the National Provider Identifier (NPI) regulation; and removal of data content that is no longer used.

  5. Who Is Affected By The Transition to Versions 5010 • Providers, such as physicians, alternate site providers, rehabilitation clinics, and hospitals • Health plans • Health care clearinghouses • Business associates that use the affected transactions, such as billing/service agents and vendors.

  6. What Is Wrong With What We Use Now? The current versions of the standards (Version 4010/4010A1) used in health care transactions lack certain functionality that will be required by the health care industry. Without the adoption of Version 5010 practices will not be prepared for ICD-10-CM and ICD-10-PCS come October 2013. It is necessary for providers to prepare for new standards in order to continue submitting claims electronically.

  7. TIMELINE FOR IMPLEMENTATION 2009 January 16: Final rule published March 17: Rule in effect Conduct internal analysis 2010 Begin internal testing (Level I) 2011 January 1: Begin testing with trading partners (Level II) Begin accepting new 5010/D.0 versions; 4010A continues 2011 continued December: Complete partner testing and dual process

  8. MANDATORY COMPLIANCE December 31, 2011: Last day CMS will accept a 4010A1 transaction JANUARY 1, 2012: MANDATORY COMPLIANCE FOR ALL COVERED ENTITIES

  9. What Do You Need To Do To Prepare? Project Plan • Gain an understanding of the impact of the update to the 5010 transactions • Look to the College and additional resources for additional information • Identify a project leader/project team and begin developing your plan

  10. Assessment • Identify all HIPAA transactions you are currently doing and any HIPAA transactions that you are not currently doing, but want to implement now electronically • Create a list of your payers, clearinghouse(s), software/system vendor’s including a contact person and phone number/email address for each • Identify the contact person and phone number of your billing service, if applicable

  11. Assessment Continued • Identify a contact person and phone number for each of your payers • Contact your vendor to determine their implementation plans for the 5010 transactions • Contact your billing service, clearinghouse(s) if applicable, to determine their implementation plans for the 5010 transactions • Contact your payers to determine their implementation plans for the 5010 transactions • Identify any work flow processes that needs to be updated

  12. Implementation • Find out when your vendor will install your updates • Identify when your billing service’s system changes will be installed, if applicable • Contact your clearinghouse(s) to determine when they can begin testing with you, if applicable • Contact your payers to determine when they can begin testing with you • Start internal testing • Complete external testing with your billing service, and clearinghouse(s), if applicable • Complete external testing with your payers • Train staff • Begin using 5010 transactions before or on January 1, 2012

  13. Monitoring • Monitor the exchange of the 5010 transactions • Report any issues identified with the transactions to the appropriate organization

  14. Helpful Questions to Ask When talking with your current practice management system vendor be sure to ask: • Will you be upgrading my current system to accommodate the 5010 transactions? • Can my current system accommodate both the data collection and transaction conduction for 5010? • Will there be a charge for the upgrade? • When will the upgrades be available? • When will the instillation to my system be completed?

  15. The biggest concern for implementation will be – “Can we avoid rejections and subsequent payment delays”? You will want to make sure your current system can be upgraded to accommodate the 5010 transactions. If there is no upgrade available you will most likely have to purchase new software or a new system. This will require intense research and a budget for the cost of a new system.

  16. Helpful Questions to Ask When talking with your clearinghouses or billing service be sure to ask: • Will you be upgrading your systems to accommodate the 5010 transactions? • When will your upgrades be completed? • Will I need to renegotiate my provider contract or electronic data interchange (EDI) agreement based on the move to the 5010 transactions? • When can I send test transactions to you to test that the system will work

  17. Can your clearinghouse still support your practice? It is important that you contact your clearinghouse(s) and billing service to see if they will continue to support your practice with the new transactions. Also you should be aware of any payers that will no longer process electronic claims using the updated transactions.

  18. Helpful Questions to Ask Questions about the data reporting requirements to consider are the following: • Can we identify the data reporting changes for the various transactions we use? • Can we find resources to assist us in identifying the data reporting changes? • What is the cost of the resources we need? • Should we use a consultant to assist us in identifying the data reporting changes? • What is the cost of hiring a consultant • Which of these new data can be stored in our current system? • Which of these data rely on the system upgrade in order to store it?

  19. Identify changes to data reporting requirements The version 5010 transactions requirements differ somewhat from the current transactions. For example there can no longer be a P.O. Box or lockbox address. With the 5010 version you can only bill actual minutes for anesthesia services. Knowing the new requirements will help ensure that you are collecting the appropriate data. A Medicare specific change is Beneficiary Matching. Medicare will require the Subscriber ID number, first name, and last name all must match the Medicare card and the date of birth must also match exactly what is on file with the Social Security Administration (SSA)

  20. Helpful Questions to Ask Questions to ask to identify staff training needs: • Who should be trained on the transaction changes? • How long will it take to train the staff on the changes? • Will there be “down time” during the training? • Should we use a consultant to conduct the training? • If so, what is the cost of a consultant? • What resources do we need for the training and to support the staff after training? • What is the cost of purchasing or creating the training resources? • When should the training be completed?

  21. Identify staff training needs • Your staff will need to make sure all transactions are • Submitted correctly • Received • Interpreted • Responded to Training should focus on understanding the transaction changes, learning the system changes, and collecting and reporting new data.

  22. Helpful Questions to Ask Questions you will likely have about testing with your trade partners (payers and clearinghouses). • Which transactions should I test? • Which trading partners should I test with? • When should I begin testing? • Will the testing be truly test data or will it utilize live production data?

  23. Your final step before you go live will be to complete testing with your partners. • Testing will involve sending test transactions through the partners you work with today (or new partners) to transmit electronically. This way you can see if the test was received successfully by both your partners system and your system. • Test with a few of your largest number or largest revenue of your transactions.

  24. RESOURCES • Comparison of Current (4010A1) and New (5010) formats go to: http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp • General Resources: http://www.cms.gov/Versions5010andD0/ • Educational Resources: http://www.cms.gov/Versions5010andD0/40_Educational_Resources.asp • AMA (includes a great 5010 checklist): http://ama-assn.org/go/5010 • CMS http://www.cms.gov/ICD10/11a_Version_5010.asp#TopOfPage

  25. MORE RESOURCES • Final Rule: http://edocket.access.gpo.gov/2009/pdf/E9-740.pdf 7/16/10

  26. American College of Cardiology Advocacy If you have any questions feel free to send an email to dmariani@acc.org

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