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HIPAA 5010

The Federal government has made it a regulatory requirement that all covered entities (health plans, health care clearinghouses, and certain health care providers) transition from HIPAA Version 4010A1 to Version 5010 when conducting electronic transactions, including:  claims (professional, institutional and dental), claims status requests and responses, payment to providers, eligibility requests and responses, referral requests and responses, enrollment and disenrollment in a health plan, coordination of benefits, and premium payments.  Even though CMS recently extended its deadline for enforcement of the 5010 transaction standard to Mar. 31, 2012 covered entities must still be fully compliant with the transition to 5010 by January 1, 2012.  To achieve 5010 compliance, more than 850 changes must be made to 4010A1 transactions.  Covered entities must not only make these changes and test them internally, but must also successfully test them with all external partners.

Time is of the essence
for meeting the January 1, 2012 compliance date, and JCS can help.  


The implementation of the new standard will require substantial changes to the content of claim data as well as modifications to software, systems, and procedures used to bill Medicare and other payers.  Providers will still need to maintain documentation that show differences in how insurers implement the transactions.

The HIPAA 5010 transaction format includes approximately 850 changes to the current HIPAA 4010A1 standard.  It includes more data elements and details both pre-existing and chronic conditions.  Successful completion of the 5010 conversion process is both a regulatory requirement and a prerequisite for successfully completing the transition from the ICD-9 to the ICD-10 code set.

The figure below provides an example of changes between 4010A1 and 5010:

HIPAA 4010 to 5010 Transaction Comparison

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Multiple Systems are Impacted by the Conversion to HIPAA 5010

The following diagram illustrates the multitude of interactive systems and processes impacted by the conversion to the HIPAA 5010 transaction standard.  Jimenez Consulting Solutions can help your organization prepare for the implementation of these new X12 and NCPDP standards.  Our team has deep, hands-on experience in planning, analysis, design, and testing of all critical systems as well as designing and executing testing with external trading partners.

HIPAA 5010 - High Level Data Flow Diagram

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Having a 5010 Conversion Strategy for Your External Trading Partners is Critical

Successful transition from HIPAA 4010A1 to HIPAA 5010 is not solely focused on making your internal systems compliant.  You must have a strategy for making sure the software vendors that support your registration, patient accounting, patient financial, and claims scrubbing systems will also be ready. You must also have a 5010 strategy for each payer and/or clearinghouse with which you transact claims.  This requires significant coordination and testing as well as a cutover strategy for each vendor and trading partner to ensure that claims and payments formatted to the 5010 standard will be properly received and returned starting January 1, 2012.  In the event that one or more of your trading partners will not be 5010-compliant by January 1, you must have a contingency plan in place to avoid, or at least minimize, the impact on claims transactions and reimbursement.  JCS’ seasoned program and project managers can help you coordinate all of these activities and create contingency plans to minimize impacts on your organization.

JCS Can Provide the HIPAA 5010 Conversion Expertise You Need

The transition to from the 4010A1 code set to the 5010 code set is challenging, and there is little time left for completing this migration.  JCS practitioners can help your organization transition successfully.  Our team can help your organization:

  • Conduct a gap analysis comparing 4010A1 to 5010
  • Identify impacts to both business and technical processes
  • Define functional requirements for system modifications
  • Develop and execute an implementation approach that incorporates both business and technical strategies
  • Complete your conversion to 5010 as quickly as possible

You can also click on the following links for information about our expertise and methodologies in other mission critical areas, such as IT Strategic Planning, ICD-10, Business Intelligence, EHRs, Evidence Based Medicine and Outcomes Management, HIEs, HIM, Program and Project Management, and Legal and Regulatory Compliance.


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Jim Gibson
Vice President & CIO
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