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How do you know you are ready for HIPAA 5010?

Providers and billing staff, if you have not yet started to make sure your system is or will soon be 5010 compliant and have all your required data elements in place to test, you may face reduced reimbursement come January 1st, 2012.   There is no talk of any delay in the timeline to date.

For managers who do not have to deal with this billing headaches, what is this 5010 fuss is all about?  It is a change in claim submission standards for covered entities per the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  For those who are new to healthcare, please don't abbreviate HIPAA as HIPPA.  You have no idea how many times I have seen HIPPA this and can't figure out what it stands for.

Examples of couple new standard changes are:  the billing provider address cannot be a PO Box, this include lock boxes or lock bins; the patient address needs to have the 4 digit extension and so on... This is why you have to start now to make changes to your process and data.

Check with your payer for their readiness and unique requirements, then test your electronic claim submission before January 2012.  Payers are “ready” when they have successfully accepted a production submission of claims (837) and returned the associated remittance (835) for these claims in compliance with the 5010 specifications.

Provider readiness means:

All system upgrades have been completed.
Confirmation of successful testing with direct submission carriers.
Confirmation of successful testing with clearinghouses.
Confirmation of successful production submission of claims.
Confirmation of successful retrieval of the claims’ associated remittance.

Payer readiness means:

All system upgrades have been loaded.
Confirmation of successful testing with direct submitting providers.
Confirmation of successful testing with clearinghouses.
Confirmation of successful acceptance of production claims (837) submission.
Confirmation of successful return of the claims’ associated remittance (835)."

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  1. Hi there, great article by HLT Consulting team! It clearly identifies and outlines the realities of the upcoming EDI / ICD-10 / HIPAA 4010 to 5010 conversion challenges. I work with a U.S. based BPO and strategic services company (headquartered in NY and with operations in India).  At the moment we are working with over 20 payer/provider companies, most of which we have already successfully converted them to 5010.  Even with our 10+ years of experience in the healthcare back office space, I’ve seen that with each conversion that new lessons are learned by our team on client specific peculiarities…and our process is now well matured. However, as time is growing short I think we are all starting to see more and more companies literally rushing now to ensure that they are ready to start submitting their claims electronically using the X12 Version 5010 and NCPDP Version D.0 standards by the January 1st 2012 deadline.  We’ll keep checking back to see if you add any new articles on the 5010 shift.  Cheers, Angela Carson, Head of Communication at Vee Technologies