Background

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves to:

• Create better access to health insurance
• Limit fraud and abuse
• Reduce administrative costs
• Accommodates the ICD-10 set change effective October 1, 2013

SDMC 5010 HIPAA-Compliant Transaction Standards to Change Effective January 1, 2012

On 1/1/2012 the Short-Doyle/Medi-Cal(SD/MC) system will accept claims in the 5010 format, as per Federal Law.

The Department of Health Care Services (DHCS), the Department of Mental Health (DMH), and the Department of Alcohol and Drug Program (ADP) have initiated a project to modify the SD/MC system to accept and process the newly mandated Health Insurance Portability and Accountability Act (HIPAA) electronic transaction version 5010.

Effective January 1, 2012, the X12 versions currently in use will be updated from X12 4010A1 to version 5010. This is required for all providers who submit administrative electronic transactions, such as checking a recipient’s eligibility, filing claims, or receiving remittance advice details either directly or through a clearinghouse. The following transactions will be updated to adopt the new standards:

Transaction Type	Title	Current Version	New Version
276/277	Claim Status Request/Response	X12N 004010X093A1	X12N 005010X212E1
835	Payment/Advice	X12N 004010X091A1	X12N 005010X221A1*
837 I	Claims: Institutional	X12N 004010X096A1	X12N 005010X223A2*
837 P	Claims: Professional	X12N 004010X098A1	X12N 005010X222A1*
999	Acknowledgment for Health Care Insurance	997 - 004010	X12N 005010X231A1*

Version 5010 is the abbreviated way to refer to Version 005010 of the Accredited Standards Committee (ASC) X12 Technical Reports Type 3 (TR3s). The TR3s are the implementation guidelines for the ASC X12, some of which are named in HIPAA, and are required when conducting transactions electronically.

5010 Training

HIPAA 5010 Trading Partner Walk Through – held on May 20, 2011 and June 9, 2011

• Training Agenda
• List of Attendees
• 5010 PowerPoint Presentation
• 4010 to 5010 High Level Overview
• 4010 to 5010 DMH Provider and Taxonomy PowerPoint
• 4010 to 5010 ADP Business Scenarios
• HIPAA 5010 Trading Partner Walk Through - June 9, 2011 recorded session – 18 Mb./1 hr 24 minutes.  Download and save this file - (WebEx Player required)
  • Download the .WRF player (Windows)
  • Download the .WRF player (Mac OS X, Intel)
    • For further WebEx Player information -  http://www.webex.com/play-webex-recording.html

5010 Testing

On March 14, 2011, Short Doyle Medi-Cal Phase II (SDMC II) system started accepting Health Care Claim:  Professional (837P), Health Care Claim Institutional (837I), and Health Care Claim Status Request (276) transactions in 5010 form for 5010 SNIP validation testing in the County Test environment.  The SDMC II 5010 DMH testing procedures are available at link below.

At this time, the SD2 system will not adjudicate 5010 test claims and 5010 835 files will not be returned.  4010 test claim will continue to be validated and processed through the entire SD2 testing environment, including returning 4010 835 results.

• SDMC II 5010 SNIP Validation Testing Procedures

Implementation Timeline

On January 16, 2009, the federal Department of Health and Human Services (DHHS) announced that updated HIPAA-compliant versions of the electronic transactions will be required for use by all health plans, providers and clearinghouses that conduct business electronically by 1/1/2012. SD/MC will reject claims in the 4010A1 format beginning on 1/1/2012.

The following are planned key dates for the implementation of X12 5010 SD/MC:

Planned Key Dates
Companion Guides SDMC II 5010 DMH Companion Guide SDMC II 5010 ADP Companion Guide	June 15, 2011 April 6, 2011
5010 Training	May 20, 2011 & June 9, 2011
System Design and Development	June through August 2011
Internal Testing	August and September 2011
Trading Partner 5010 Testing	October 2011
Live Implementation- Compliance Deadline for HIPAA 5010	January 1, 2012

5010 Cut-Over Approach

On December 14, 2011, DMH released the 4010 to 5010 Cut-Over Approach to the Trading Partners.   Cut-Over Resolution - December 7, 2011

 

HIPAA 5010 - Other Resources