Preparing for Version 5010

By Doug Nixdorf

With contributions from Susan Hopper

January 2012 seems a long time from now, but in HIT time, it’s not. In addition to the technical changes, there are workflow and policy changes to plan and execute, all while maintaining service levels and timely reimbursements.

The U. S. Department of Health and Human Services (HHS) announced the final rules in February this year. Healthcare organizations must transition to an electronic environment and update standards for electronic healthcare and pharmacy transactions including:

• Professional and institutional claims
• 835 remittance advices
• Eligibility
• Claims status requests and responses 

Under the authority of HIPAA, the current versions of standards for the above electronic health care transactions, (e.g., version 4010/4010A1) will be updated to version 5010.  Compliance deadlines are as follows:

• Covered entities must comply with 5010 transactions on January 1, 2012. 
• Medicaid subrogation compliance is set for January 1, 2012.
• Small health plans have an additional year to comply on January 1, 2013. 

The new HIPAA standard 5010 includes more specific directions for EDI claims. These new formats provide many changes to the current 4010A version such as modified subscriber and hierarchy, clarification of pay-to-provider usage, clarification of Coordination of Benefits (COB), and refined reversal and corrections instructions,  to name a few.

5010 action steps

From now until 2012, your organization may have multiple, large IT-related initiatives including the transition to the ICD-10 code sets, and preparing and applying for ARRA stimulus funding – let alone your own organization’s projects.  It’s going to be pretty important to plan and staff all of these huge projects. Here are our suggestions (below). If you have some to add, please post comment and if we agree, we’ll add it in.

1. Perform a gap analysis

• Verify your organization’s compliance timeframe.
• Identify your current 4010A formats and pharmacy transactions.
• Identify the differences between your 4010A custom guidelines and the new 5010 standard guidelines.
• Document related business rules, review to determine need and place into matrix for conversion work.
• Evaluate and define current processing, policies and procedures.
• Establish measurable goals and objectives for 5010 compliancy.
• Estimate and plan budget for 5010 resources, timing and fiscal planning through 2012.
• Coordinate efforts with ICD-10 and other initiatives to avoid duplication of work.
• Develop communication plan and decision matrix (internal and external).

2. Execute the migration to 5010

• Translate your organization’s business rules into the 5010 standard.
• Update processes and maintenance protocols.
• Finalize testing plan and success criteria.
• Set up and coordinate go-live plans with upstream and downstream business partners.
• Coordinate use of 5010 as pre-requisite for ICD-10 sets.

3. Test

• Develop a 5010 testing plan for:
• Single file validation
• Regression testing
• Mass parallel testing
• Business rules
• Test processes and perform a go-live dress rehearsal.
• Test internal and external, upstream and downstream 5010 files.
• Test new format with vendors.

4. Training

• Identify affected users and develop new processes to accommodate expanded business needs.
• Communicate implication of new business rules.
• Establish training plan, considering:
• Audience
• Effort
• Competency requirements
• Execute training

5. Go live

• Ensure adequate support staffing for go live and transition period.

Overall, it’s important to start to task staff members with these steps now, while time is still on your side. A smooth transition will help ensure that your organization’s revenue is minimally interrupted.

Doug Nixdorf, Hayes Healthcare Consultant, is a seasoned GE Healthcare subject matter expert with expertise in all aspects of billing office operations. A former Business Systems manager, he is familiar with the responsibility for all claims production as well as the integrity of the GE/IDX system.

Susan Hopper, Hayes Healthcare Consultant, has 25 years of management and consulting experience, specializing in complex project management. She is also a subject matter expert on front desk systems and workflow.