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HIPAA Standards Conversion 4010A1 to 5010

The secretary of the Department of Health and Human Services has adopted Accredited Standards Committee X12 Version 5010 as the next Health Insurance Portability and Accountability Act (HIPAA) standard for HIPAA covered transactions. The final rule was published Jan. 16, 2009.

What is the Timeline?

The National Committee on Vital and Health Statistics and the Department of Health and Human Services have recommended the following level I and level II compliance dates to ensure full, successful and timely compliance:

Date Compliance Deadline
March 17, 2009 Effective date of the regulation
Dec. 31, 2010 Level I compliance *
Dec. 31, 2011 Level II compliance**
Jan. 1, 2012 All covered entities must be fully compliant

* Level I compliance means that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design or build activities and internal testing.

** Level II compliance means that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards.

Who is Affected by the Transition to Version 5010?

HIPAA covered entities affected by the transition to Version 5010 include the following:

  • 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
What Changes Must Occur with Version 5010?
  • The formats currently used must be upgraded from X12 Version 4010A1 to Version 5010. For Medicaid, the HIPAA-mandated formats include the following: Claims 837-I, 837-P, 837-D
  • Remittance Advice 835
  • Claim Status Inquiry/Response 276/277
  • Eligibility Inquiry/Response 270/271
  • Prior Authorization 278

Two additional formats, not mandated by HIPAA, will also be adopted by Medicaid Fee-for-Service. These acknowledgement transactions include the following:

  • Transaction Acknowledgement (TA1)
  • Functional Acknowledgement (999)
How is Kentucky Medicaid Preparing for 5010?

The Kentucky Medicaid program along with the fiscal agent Hewlett-Packard (HP) is currently working on implementation activities to convert from the HIPAA ASC X12 Version 4010A1 to ASC X12 Version 5010.

Over the next year Kentucky Medicaid along with the fiscal agent HP will update the following websites with 5010 information to keep providers, vendors and clearinghouses informed of resources and instructions.

  • KY Medicaid Management Information System_ is a resource for providers, vendors and clearinghouses
  • KY Health Net is a free web-based application for providers to submit claims, claim status and verify member eligibility
  • Department for Medicaid Services website is a resource for providers, vendors and clearinghouses
How Do I Recieve Updated 5010 Information or Ask 5010 Questions?

For updated 5010 information

By email to KY EDI Helpdesk with the subject line: 5010 Contact Information. Please include your current Trading Partner ID and 5010 contact information or you may contact the EDI Helpdesk at (800) 205-4696.

For 5010 questions

Send all 5010 questions to the KY EDI Helpdesk or call Monday through Friday 7 a.m. – 6 p.m. EST (800) 205-4696.

 

Additional Resources
  Centers for Medicare and Medicaid Services

Federal Register

Edifecs

5010 HIPAA Implementation Guides
5010 TR3s (Technical Report Type 3). These guides can be purchased at Washington Publishing Company
 

Forms and Publications
 

Provider Letters

Forms

  • 5010 Contact Form
  • MAP 246 - Agreement between the KY Medicaid Program and Electronic Billing Agency
  • Map 380 - Agreement Between the Kentucky Department for Medicaid Services And the Kentucky Medicaid Provider

Publications

 

Attention Providers! KY Medicaid and HP Enterprise Services EDI Unit now has EDI testing available.
 

For more information on what you need to do, please refer to the EDI Testing Steps.

 

Last Updated 7/17/2012
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