WPS Health Insurance

5010 Readiness

The Health Insurance Portability and Accountability Act of 1996 mandated that the healthcare industry use standard formats for electronic claims and claims related transactions.

On January 15, 2009, the Secretary of the Department of Health and Human Services (HHS) adopted ASC X12 version 5010 and NCPDP version D.0 as the next standard for HIPAA covered transactions.

The final rule was published and HHS issued regulation specifying that updated versions of the standards must be adopted by the industry.

5010 Affects the following Business Processes

  • Claims (837 Institutional, Professional, Dental, COB (Professional and Institutional) and , NCPDP)
  • Claim Status Inquiry/Response (276/277)
  • Remittance (835)
  • Enrollment (834)
  • Premium Payment (820)
  • Eligibility Inquiry/Response (270/271)
  • Referrals and Prior Authorizations (278)
  • Claims Acknowledgements (277CA)
  • Acknowledgement for Health Care Insurance (999)

Systems that submit claims, receive remittances, exchange claim status or eligibility inquiry and responses must be analyzed to identify software and business process changes.

Centers for Medicare and Medicaid Services (CMS) has prepared a side-by-side comparison of the 4010A1 and 5010 ASC X12 claim, remittance, claim status and eligibility inquiry/response versions, which are available on the CMS Electronic Billing & EDI Transactions website.

New ASC X12 standard acknowledgement (999) and rejection transactions (TA1) will be utilized.

Additionally the Claims Acknowledgement (277CA) will be used to replace proprietary error reporting (e.g. prepass report).

Billing staff will likely need human readable reports produced using the 999 and 277CA transaction in order to identify claim corrections before resubmission. Clearinghouses and Vendors may consider offering a 999 and 277CA reporting capability.

Additional Information regarding 5010

Purchase of Implementation Guides and access to Technical Questions X12:

CMS Website for industry wide information:

5010 Changes for Invalid Alpha Numeric (AN) Characters

Recently Medicare contractors addressed an issue regarding invalid (AN) characters present on 5010 inbound claims. Currently claims submitted with an invalid AN character are set up to reject at the CEM (Common Edit Module) at a claim level via a 277 claims acknowledgement (277CA). It is non compliant to generate a 277CA with an invalid AN character.

As of July 5, 2011, if an invalid AN character is submitted on a 5010 inbound file, the claim will reject at the translator level and not be sent to the CEM for further processing.

Important Information
´╗┐