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5010 Information Resource


1.      What is 5010:

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:

o   837i  Institutional Claims

o   837p  Professional Claims

o   837d  Dental Claims

o   835  Claims Remittance Advice

o   834  Enrollment

o   270/271  Eligibility Inquiry and Response

o   276/277  Claim Status Inquiry and Response

o   278  Referral Authorization and Certification

These current versions of the standards (the Accredited Standards Committee X12 Version 4010/4010A1) for health care 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 with Version 5010.


2.      What 5010 Covers:

Version 5010 of the HIPAA standards includes improvements in structural, technical, and data content (such as improved eligibility responses and better search options). It is more specific in requiring the data that is needed, collected, and transmitted in a transaction (such as tightened, clear situational rules, and in misunderstood areas such as corrections and reversals, refund processing, and recoupments). Further, the new claims transaction standard contains significant improvements for the reporting of clinical data, enabling the reporting of ICD 10 CM diagnosis codes and ICD 10 PCS procedure codes, and distinguishes between principal diagnosis, admitting diagnosis, external cause of injury and patient reason for visit codes. These distinctions will improve the understanding of clinical data and enable better monitoring of mortality rates for certain illnesses, outcomes for specific treatment options, and hospital length of stay for certain conditions, as well as the clinical reasons for why the patient sought hospital care.


3.      What needs to be done to get prepared (Update PM software/processes, etc.):

This upcoming X12 format change affects all healthcare providers and Trading Partners who submit any of the HIPAA transaction code sets. Blue Cross of Idaho urges you to contact your practice management software or claim submission vendor to ensure they take appropriate steps to prepare your billing system for the change.  Blue Cross of Idaho has taken steps to help you to be better prepared for this change, by sending provider and clearinghouse surveys.  These 5010 surveys along with a 5010 readiness checklist will help you and Blue Cross of Idaho get a jumpstart on this complex upgrade.


4.       Key Dates:

·         Testing and Dual Use HIPAA versions 4010A1 and 5010 begin: July 1, 2011

·         5010 Only- HIPAA version 5010: January 1, 2012

*Please Note: 5010 is a precursor to the ICD-10 update which is scheduled for October 1, 2013

Please refer to the CMS website for further details:  


FAQ's Regarding 5010



Frequently Asked Questions about the new HIPAA 5010 process


Below are some frequently asked questions about the implementation of the new HIPAA 5010 process. We will add questions and answers to this list frequently so please refer back for updates.


Q: When do providers have to begin submitting electronic claims in the new 5010 format?

A: CMS mandated providers submit all electronic claims in the new 5010 format beginning January 1, 2012.


Q: If I submit paper claims, am I subject to the CMS mandated change to the new 5010 format January 1, 2012?

A: The 5010 rule only applies to electronically submitted claims, not paper. We encourage all providers to submit claims electronically in the new 5010 format beginning January 1, 2012 to improve our efficiency and speed at processing your claims.


Q: What do providers need to do to ensure they are 5010 compliant on January 1, 2012?

A: Contact your practice management system vendor or billing service to determine when their 5010 software version will be ready and when you can upgrade your system(s).


Q: I am ready to submit my electronic claims in the new 5010 format, but when will Blue Cross of Idaho be ready to receive and process my 5010 claims?

A: Blue Cross of Idaho will be ready to accept electronic claim submissions in 5010 format beginning mid October.


Q: Are admission dates required on outpatient UB04 claim forms?

A: No, if admission dates are included on an outpatient UB04 claim, EDI will error the claim.