Provider organizations that conduct business electronically were made aware of two significant changes to HIPAA standard transactions and code sets. The Department of Health and Human Services announced the following compliance deadlines:

  • New HIPAA standards known as version 5010 became effective January 1, 2012.
  • ICD-10 codes replaced ICD-9 diagnosis codes for use in outpatient and inpatient settings and replaced ICD-9 procedure codes for inpatient settings beginning October 1, 2015. CPT codes remain the codes used by physicians for reporting procedures in outpatient settings.

HIPAA 5010

In addition to the new 5010 version of the x12 standards for HIPAA EDI transactions, new versions of the National Council for Prescription Drug Program (NCPDP) standards must be met, including:

  • Pharmacy and supplier transactions (Version D.0)
  • Medicaid pharmacy subrogation (Version 3.0)

Covered entities must use these standards for pharmacy and supplier transactions including: claims, eligibility requests and responses, referral certification and authorization, and Coordination of Benefits.

Updated 5010 standards improve the functionality of HIPAA-regulated transactions and help to meet current business requirements such as better Present on Admission (POA) reporting on claims, improved use of NPI numbers, and greater detailed eligibility information needed by healthcare providers making treatment decisions.

For more information on the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards for electronic health care transactions, x12 version 5010 transaction standards and code sets, visit the CMS version 5010 website.

Also, read our HIPAA 5010 frequently asked questions.

Questions?

For further information, contact Blue Shield’s EDI Support Team at:

Phone:(800) 480-1221

Email:BSC_EDI@blueshieldca.com