Gap analysis between 4010 and 5010 transaction

HIPAA 5010 – Introduction

Centers for Medicare and Medicaid Services [CMS] revised the timeline for adoption of HIPAA 5010 to 1st
Jan 2012. ASC X12 HIPAA 5010 is the upgraded version of HIPAA 4010 standards, with the core
objective of addressing the shortcomings of its predecessor. HIPAA 5010 addresses the challenges faced
by healthcare organizations globally and cater for the improvement suggestions from 4010
implementation. A major feature of HIPAA 5010 is the support for ICD-10 implementation. HIPAA 5010
has a significant role to play in lowering the overall healthcare cost by focusing on improving the efficiency
of transaction processing as a whole.

Different transactions are specified in the HIPAA 5010 standards

• 270/271 – Health Care Eligibility Benefit Inquiry and Response

• 276/277 – Health Care Claim Status Request and Response
• 278 – Health Care Services – Request for Review and Response; Health Care Services
Notification and Acknowledgment
• 820 – Payroll Deducted and Other Group Premium Payment for Insurance Products
• 834 – Benefit Enrollment and Maintenance
• 835 – Health Care Claim Payment/Advice
• 837 – Health Care Claim (Professional, Institutional, and Dental), including coordination
Of benefits (COB) and subrogation claims

Major differences between HIPAA 4010A1 and HIPAA 5010

There are changes across all of the transactions, some of which include

• The ability to support new-use cases brought forward by the industry;

• Clarification of usage to remove ambiguity;
• Consistency across transactions;
• Support of the NPI regulation; and
• Removal of data content that is no longer used.

HIPAA 5010 – Benefits

The benefits of HIPAA 5010 can be summarized at a high level as outlined below:-

 Reduction in customer service call volumes

 Easier to interpret guides and front matter
 Improved efficiency and overall usability
 Reduced administrative costs
 Improved eligibility verifications
 Possible claim auto adjudication improvements
 Financial savings due to all of the above

ASC X12 Changes Required by HIPAA 5010

ASC X12 5010 Major Changes

Transaction
834  Ability to report new control totals in QTY segment [e.g., Employee Total
(ET), Dependent Total (DT) and Transaction Total (TO)]
 New set of qualifiers to support new maintenance reason codes (e.g.,
addition or deletion of a dependent due to student status change, limiting
 age of dependent)
 Privacy related improvements - drop off location separate from home
 ICD -10 support to report pre-existing conditions
820  RMR — Individual Premium Remittance Detail segment changed from
situational to Required
 Added premium receiver’s remittance delivery method
 Added service, promotion, allowance, or charge information loop
270  Required alternate search options
 Added support for 38 new Patient Service Type codes
 Burn care, brand name prescription drug (formulary and non-formulary),
coronary care, screening x-ray and laboratory
271  Requires payer responses to include
 How to report patient on subsequent transactions
 Plan name, effective dates, required demographic info
 Nine categories of benefit information must be reported: medical care,
chiropractic care, dental care, hospital, emergency services, pharmacy,
professional visit — office, vision, mental health, urgent care
278  Restructured to support patient event and service level requests which
aligns transactions closer to claims
 Enable service level to support institutional, professional, and dental detail
segments
 Medical services reservation (Medicaid)
 Added support for ICD-10
837 (P/I/D)  Added support for ICD-10
 Present on Admission indicator for institutional claims
 Ambulance pick-up and drop-off locations
 Remaining patient liability (clarifies COB — 837I and P)
 National health plan ID (to support when identifier is adopted)
 837P anesthesia minutes
276/277  Subscriber and dependent loop data were made more consistent
 Eliminated sensitive patient information that was unnecessary for business
purpose
 Added pharmacy-related data segments and the use of NCPDP Payment
Reject Codes

HIPAA 5010 - Change Statistics

Loop change statistics is composed of:-

Modified loops
New loop HIPAA Loop Field
Obsolete loops Transactions Changes Changes
837P 55% 40%
Field change statistics is composed of:- 837I 59% 39%
835 No changes 13%
New field 276 36% 21%
Deleted field 277 28% 22%
Modified field
Data length changes
Data value changes
Usage change (Required/Situational)
HIPAA 5010 - Transactions and IT Impact

837/835
Change Description Impact
Subscriber Subscriber information is needed only when the patient Logic
information* cannot be uniquely identified
NPI* Billing provider is the detailed subpart. Resolves the Logic, Structure,
failures in payer-to-payer COB Interface
ICD-10* Added support for ICD-10-CM & ICD-10-PCS code Logic, Structure,
Interface
Payer specific providerAssociates the provider with specific payers. This helps Logic, Structure,
IDs* to improve the claim adjudication efficiency greatly Interface
Billing provider Clear articulation for billing provider definition. Reduces Logic
the errors in payer-to-payer COB
Outpatient Standardizes the provider type definition, inpatient & Logic
visits/Other provider outpatient visits based on NUBC standards
COB Redundant amount columns have been removed Logic, Structure,
improvements Clear guidance to submit and balance COB Interface
Pay to plan Provides for pay-to-plan name and address. This helps Logic, Structure,
in electronic processing of Medicaid subrogation of Interface
payers
Present on Provides for present on admission indicator related to Logic, Structure,
admission each diagnosis code Interface
Obsolete data Removed all data requirements which were obsolete in Logic, Structure
nature. Example – Date of similar illness
Anesthesia Requires anesthesia services to be reported in minutes Logic, Structure
services instead of units
Diagnosis codes Provides for increased number(12) of diagnosis codes Logic, Structure
*These changes also impact 835

270/271
Change Description Impact
Payer response Provides for increased categories of benefit information Logic
Service type Provides for 45 new service type codes corresponding Logic
codes to the new codes in 270
COB coverage Provides for linkage between COB payer & subscriber Logic
information
Alternate search Provides for options to indicate additional search Logic
options parameters
Patient service Provides support for 45 new patient service type codes Logic
type codes

278
 Change Description Impact
Inquiry response Provides for inquiry on certification decisions Logic
Notification Provides for Logic
 Unsolicited health care service review
information among providers, payers, UMO, etc
 Notification of scheduled events
 Notification of certification changes

834/820
Change Description Impact
Subtotals Provides for sub totals by employee, dependents etc. Logic,
This helps in data accuracy & audit Structure
Reporting Provides for the client to report classification details for Logic,
category loop the data Structure
Maintenance Provides for codes to add delete dependents, monitor Logic,
reason codes customer satisfaction etc Structure
Subscriber Provides for options to support privacy laws & individual Logic,
privacy options privacy requirements Structure
ICD-10 Added support for ICD-10-CM & ICD-10-PCS code Logic, Structure,
Interface
Remittance Provides for options to indicate payment method Logic,
delivery method Structure
Charge Provides for option to report additional deductions to Logic, Structure,
information loop payments Interface

276/277
Change Description Impact
Subscriber Provides for consistent subscriber and dependent loop Logic
information data
Privacy Sensitive patient information unnecessary for business Logic
process has been removed

HIPAA 5010 - Major Functional Changes in 837

Standardization of provider type identification

Provider types are redefined in conjunction with NUBC (National Uniform Billing Committee) code set.
This will ensure consistent implementations and requirements in line with nationally accepted guidelines
from the NUBC.
4010 5010
Key Benefits
Non-standard qualifiers Standard NUBC codes
Payer - This will enable payer to clearly identify used could assign wrong will be used for provider
the provider type on the 837 claim and thus provider type and may type identification
perform better provider contract management delay the claims
in the benefit adjudication systems. processing

Provider - Easy and accurate 837 data entry.

Better instruction for implementation of NPIs
Added clearly defined rules as to how NPI
subparts are to be reported structurally. 4010 5010
Healthcare provider organization with
Identification of provider Provider identification
enumerated subparts will report NPI of a
Subparts are inefficient. Becomes more specific
subpart as the billing provider.
at organization level as
well as subparts level.
Clear and precise rules to ensure that the
provider information is reported in the same Ambiguity for handling Specific rules to ensure
position and with the same meaning regardless providers practicing in data quality and to
of who the receiver is. Multiple locations. streamline provider
identification.
The Taxpayer Identifying Number (TIN) of the No possibility of Provider Provider identification in
billing provider to be used for IRS Form 1099 –To-Payer–to- Payer the payer loop will
purposes must be reported. model for COB claims. ensure Provider-to-
Payer-to-Payer model.
The billing provider’s payer specific proprietary identifiers were moved to the destination and non-
destination payer loops. This change enables non-ambiguous reporting of proprietary provider identifiers
by implicitly associating the identifier with the payer. For COB the applicable billing provider identifier can
now be clearly delineated for each payer in the claim.

Key Benefits

Payer - NPI implementation is tied with the proprietary provider ids. Streamlines duplicate claim
determination process.

Provider - Possibly, less administrative overhead for submitting COB claims. Easy and accurate data
entry

Standardization of COB Information

Front Matter instructions are added to ensure a

standard implementation. This includes:- 4010 5010
Ambiguous information More structured data to
 Creating an 837 COB claim when the
in COB loops because of help improve COB
primary payer’s remittance information
Redundant data. processing.
to the provider is not in 835 format
(paper remit). No 835/837 Cross-walk 835 / Paper remittance
Available. to 837 cross-walk
 Balancing a COB claim based on improves data quality
primary payer’s information. and balancing of
amounts in the COB
 Rules defined for calculating the Scenario.
primary payer’s allowed and approved amount. This results in the elimination of several amount
segments.

Key Benefits

Payer - Improved and accurate COB claim submission. This could enhance the claims auto adjudication
rate.

Coordination of Benefits - Medicaid Subrogation

New data elements will provide ability for
trading partners to allow direct billing by a 4010 5010
Medicaid agency to other health plans.
No support for COB for Supports COB for
Medicaid programs. Medicaid programs thus
Key Benefits
reducing administrative
cost.
Payer - Reduced admin cost by introducing
COB for Medicaid programs. Claim processing of Medicaid supporting products would become easy.

Provider - Faster claim payment on Medicaid claims.

Reporting of anesthesia time in minutes

This ensures consistency and clarity across

transactions and avoids confusions among 4010 5010
providers and plans. This also avoids manual
Lacks consistency in Ensures consistency
or electronic conversion of units to minutes or
reporting anesthesia and clarity across
vice versa depending on a health plan’s
time in either units or transactions.
requirement. This can get complicated in COB
minutes.
transactions when the secondary and/or tertiary
payer’s have varying requirements than No provision for Anesthesia provider
primary. additional anesthesia can report additional
time for obstetric complexity beyond the
services. normal obstetric
services reflected by
the procedure base
units and anesthesia
time.

Support for ICD-10 codes

The need to migrate to ICD-10 code is the most compelling driver for implementation of HIPAA 5010
would not be an understatement. The overall nature of the change is significantly vast.