HIPAA Transaction Standards
The Health Insurance Portability and Accountability Act (HIPAA) requires that electronic transactions be transmitted using standard formats.
HIPAA Transaction Standards are Changing
On January 1, 2012, the current 4010/4010A1 transaction standards will no longer be accepted. All entities transmitting and receiving electronic health care transactions must do so using the new 5010 version of the standards.
This will require upgrading or the replacement of software currently used to conduct electronic transactions, such as claims submissions, eligibility inquiries and receipt of electronic claims acknowledgments and reports. This transition is also a necessary step to prepare for the October 1, 2013 change from reporting ICD-9-CM to ICD-10-CM diagnosis codes.
This will require upgrading or the replacement of software currently used to conduct electronic transactions, such as claims submissions, eligibility inquiries and receipt of electronic claims acknowledgments and reports. This transition is also a necessary step to prepare for the October 1, 2013 change from reporting ICD-9-CM to ICD-10-CM diagnosis codes.
Prepare for the Change
Practices should begin now to identify the effect of this change in standards to their practice and plan ahead for:
- Computer system upgrades and any direct costs associated with upgrades
- Testing of new transactions with clearinghouses and payers
- Training of staff related to any changes in what information is required for 5010 transactions
This will likely involve conversations with software and hardware vendors and system support staff, clearinghouses and payers.
Changes notable to physician practices
Some changes that physician practices should take note of are:
- You may continue to use a P.O. Box address in the "pay to" information on your claims but a physical address is required in the billing provider information (the 2010AA loop).
- You must include 9-digit zip codes with billing and service facility locations.
- Version 5010 will include a pay to plan loop (2010AC) that allows addition of information about a payer that has paid a claim under subrogation rules.
- Up to 12 diagnosis codes may be submitted on a claim.
- A paperwork section of the claim will notify Medicare that you are sending additional documentation to support a claim and an ID number of your choosing that will connect the claim and the documentation. Your Medicare Administrative Contractor (MAC) will provide a cover sheet for faxing or mailing the documentation to them. The ID number you assigned in your claim will be included on the cover sheet so that the documentation can be added to the claim.
