Standards: HIPAA 5010 - Why is this important to HIMSS members? 

HIPAA remains at the forefront of healthcare, and there are many components to this complex set of standards. Critical components of HIPAA are transactions and code sets, which many organizations and individuals in the industry are actively working on. Most often, we hear references to HIPAA 5010, so what is 5010 and why is it important to HIMSS members? 5010 is the latest version of proposed HIPAA’s transaction standards from the ASC X12 standards development organization.  There are also proposed NCPDP standards version D.0 to update the Pharmacy transaction standards for HIPAA, which are not discussed in this article.  WEDI and NCHICA jointly developed an industry timeline that suggests the implementation of the updated HIPAA transactions won’t be completed until 2014.

The ASC X12 version 5010 transactions (a.k.a. version 5010) focus on the electronic exchange of administrative and financial information between health care providers and health plans for patient care services, including eligibility inquiries, service (treatment) authorization and referrals, claims status requests, claims and remittance advice (claims payment). The updated HIPAA transactions (ASC X12 and NCPDP) also play a critical role with the future of ICD-10. Clearly, HIPAA’s transactions updates impacts all healthcare stakeholders, from hospitals, pharmacies, physician offices, payors, billing software vendors and clearinghouses to consumers with this sector taking on more significant responsibility for service payment.  

To shed light on this topic, Financial Edge spoke with someone who is considered a leading expert on ASC X12 5010 transactions—Don Bechtel, a Standards and Regulatory Manager for Siemens Healthcare and Chief Privacy Officer for Healthcare Data Exchange (HDX), a division of Siemens Healthcare. Mr. Bechtel contributes his extensive health IT experience through active participation and leadership in various industry forums on behalf of Siemens, including WEDI’s Board of Directors and ASC X12 Insurance Subcommittee and its Health Care Task Group.

1. Why is it important for us to move from the current version of HIPAA to HIPAA 5010?  

The current version of X12 HIPAA transactions are 8-years-old at this point.  When the industry first developed and implemented the ASC X12 version 4010 transactions (a.k.a. version 4010), the X12 standards developers for the healthcare transactions worked hard to develop standards that would meet most industry needs. But, this being the industry’s first attempt at defining national EDI transaction standards for all health care stakeholders (which until that time were done manually via phone or by paper or when done electronically used proprietary formats with proprietary code sets and had very little industry consistency) some problems were encountered. It’s fair to say that the version 4010 transactions are good standards but the problems that were encountered made implementation difficult and often required workarounds; thus, the transactions were less effective.  Version 5010 will eliminate those early workaround solutions. 

Also, since version 4010 was implemented, the industry has asked for more than 500 changes to the standards to support new business requirements or to correct old problems. These changes, available in version 5010, will improve the functionality of the HIPAA transactions, bring more value to the users, and meet many new needs for current business requirements, such as better POA reporting on claims, improved use of NPI numbers and a more functional eligibility transaction that will provide greater detailed information needed by healthcare providers when making treatment decisions. 

In HIPAA version 5010, the authorization and referral transactions are significantly improved, removing many of the implementation obstacles that were initially encountered. Also, necessary medical information has been added to allow health plans to make more timely and efficient decisions for authorizations. The remittance transactions have not changed much, but the implementation instructions are much improved, providing clear guidance to health plans on how to populate the transaction. These changes will significantly reduce many of the problems that have prevented providers from automating their reimbursements.  Collectively, version 5010 will bring many improvements and new features to all stakeholders.

2. What would the benefits of the new version be to HIMSS' members; for example, to CIOs and healthcare providers? 

As previously mentioned, the eligibility transaction, for one, will be greatly improved. New implementation rules will require health plans to provide fuller, more complete benefit and coverage information about a patient, thus eliminating many phone calls that are still needed today. The new claim transactions and instructions should to help to reduce AR days by bringing faster payments. Currently, claims are often denied because they are not properly coded or completed due to ambiguous instructions, confusing data requirements, or payer specific workarounds. 

With HIPAA version 5010, more automated processing will be possible for secondary claims. A much improved authorization transaction should reduce staff time spent making phone calls to health plans and care managers for treatment approvals. Health plans will be able to populate remittance transactions more accurately and completely, allowing providers to automate the claims payment functions that now are still manual for many provider organizations.

3. What does the industry need to do now to move forward toward implementing HIPAA 5010—with a suggested implementation date of 2014? What challenges/issues would our members face given that timeframe?

I believe the adoption of version 5010 is imminent, and providers, health plans and clearinghouses need to acquire the new version 5010 Implementation Guides and begin to do their gap analysis between versions 4010 and 5010. They need to pay close attention to the changes in the business rules, not just the physical changes to the transactions (the devil is always in the detail). Many improvements for version 5010 come from more specificity in the business rules that need to be applied when making decisions about what information must be provided in a transaction, and under what conditions. The rules have become much more “true or false” type evaluations to help ensure consistency. 

As for the timeline, I believe the current industry timeline project has overstated some of the work that will need to be done. The 2014 date is much too long; I believe this could be done at least 2 years sooner. I'm sure there are areas for improvement in the timeline, but those won't happen without the industry getting involved in the work that is being lead jointly by WEDI and NCHICA. It would be great if more people could look at the details of that plan and help to identify areas that could be improved or better defined. The current plan makes a number of assumptions based on what happened during implementation of version 4010. Some of those assumptions were good learning experiences, while others are not realistic and should be re-evaluated. One example is the time it will take HHS to publish a final rule; this I believe can occur much sooner than is currently documented in the timeline.   

For additional information on 5010, please see the HIPAA 5010 update Mr. Bechtel gave to the NCVHS' Subcommittee on Standards and Security last July. His presentation is available at http://ncvhs.hhs.gov/070730p4.pdf.

Also, another industry initiative supporting this work effort is CAQH CORE (http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=175). CORE efforts provide the business rules around implementation of code sets. Look for additional information on CORE in future editions of Financial Edge.