This site's objective is to communicate to providers, clearinghouses, and vendors
the information needed to convert from the HIPAA 4010A1 version of transactions to
the 5010 version. At this time all entities that send claims to Arkansas BlueCross
and BlueShield must be using the X12 5010 and NCPDP Version D.0 standards by January 1, 2012.
Visit the 5010 resource center often in 2011 for the latest information and timelines.
The Health Insurance Portability and Accountability Act (HIPAA) requires the Secretary
of the Department of Health and Human Services (HHS) to adopt standards that covered
entities (health plans, health care clearinghouses, and certain health care providers)
must use when they electronically conduct certain health care administrative transactions,
such as claims, remittance, eligibility, claims status requests and responses, and others.
The Transactions and Code Sets final rule published on Aug. 17, 2000, adopted standards
for the statutorily identified transactions, some of which were modified in a subsequent
final rule published on Feb. 20, 2003.
These current versions of the standards (the Accredited Standards Committee X12 Version
4010/4010A1 for health care transactions, and the NCPDP Version 5.1 for pharmacy transactions)
are widely recognized as lacking certain functionality that the health care industry needs.
On January 16, 2009, HHS announced a final rule that replaces the current Version 4010/4010A
and NCPDP Version 5.1 with Version 5010 and Version D.0, respectively.
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.
The Administrative Simplification Compliance Act (ASCA) requires the use of electronic claims
(except for certain rare exceptions) in order for providers to receive payment. Therefore,
effective January 1, 2012, 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. Arkansas BlueCross and BlueShield will provide additional information
to assist you and keep you apprised of progress on our 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. While the new claim format accommodates the ICD-10 codes, ICD-10 codes will not be accepted
as part of the 5010 project.
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.
http://www.wpc-edi.com/content/view/711/401/ - Washington Publishing Company Health Care Code Sets
http://www.cms.gov/versions5010andd0/ - Central Version 005010 and D.0 webpage on CMS website
Health Advantage is an Independent Licensee of the Blue Cross and Blue
Shield Association and is licensed to offer health plans in all 75 counties in Arkansas.
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