An Introductory Overview of the HIPAA 5010
Provider Types Affected
All physicians, providers, and suppliers who bill Medicare Carriers, Fiscal Intermediaries (FIs),
Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment MACs (DME MACs) for
services provided to Medicare beneficiaries
What You Need to Know
STOP – Impact to You
The implementation of HIPAA 5010 presents substantial changes in the content of the data that you
submit with your claims as well as the data available to you in response to your electronic inquiries.
The implementation will require changes to the software, systems, and perhaps procedures that you use
for billing Medicare and other payers. So it is extremely important that you are aware of these HIPAA
changes and plan for their implementation.
CAUTION – What You Need to Know
The Administrative Simplification Act (ASCA) requires the use of electronic claims (except for certain
rare exceptions) in order for providers to receive Medicare payment. Therefore, you must be ready to
submit your claims electronically using the X12 Version 5010 and NCPDP
Version D.0 standards. This also is a prerequisite for implementing the new ICD-10 codes. The Centers
for Medicare & Medicaid Services (CMS) will provide additional information to assist you and keep
you apprised of progress on Medicare’s implementation of HIPAA 5010 through a variety of communication
vehicles. Remember that the HIPAA standards, including the X12 Version 5010 and Version D.0 standards,
are national standards and apply to your transactions with all payers, not just with Fee-for-Service
(FFS) Medicare. Therefore, you must be prepared to implement these transactions with regard to your
non-FFS Medicare business as well. Medicare expects to begin transitioning to the new formats January
1, 2011 and ending the exchange of current formats on January 1, 2012. While the new claim format
accommodates the ICD-10 codes, ICD-10 codes will not be accepted as part of the 5010 project.
GO – What You Need to Do
In preparing for the implementation of these new X12 and NCPDP standards, providers should also
consider the requirements for implementing the ICD-10 code set as well. You are encouraged to
prepare for the implementation of these standards or speak with your billing vendor, software
vendor, or clearinghouse to inquire about their readiness plans for these standards.
CMS Progress in Implementing the New Standards
CMS is well into the process of readying its FFS Medicare systems to handle the 5010/D.0 standards.
All Medicare systems will be ready to handle the new standards by January 1, 2011. Medicare
plans for its systems to handle the current 4010A standard and the new 5010/D.0 standards for
incoming claims and inquiries and for outgoing replies and remittances from January 1, 2011
until January 1, 2012. This will allow providers who are ready to begin using the new standards
on January 1, 2011, while providing an additional year for all providers to be ready.