HIPAA Version 5010 Deadline Approaching – Avoid Common Claims Rejections

The June 30, 2012 deadline of the compliance enforcement discretion period for all HIPAA-covered entities to complete their upgrade to the HIPAA Version 5010 electronic standards is quickly approaching.

The Centers for Medicare & Medicaid Services' (CMS) Office of E-Health Standards and Services announced that it will be ending its enforcement discretion period for Version 5010 standards on June 30, 2012. This means that all HIPAA-covered entities must be fully compliant with all of the upgraded transaction standards for ASC X12 Version 5010 (Version 5010) and NCPDP Versions D.0 and 3.0. 

As June 30 draws near, TriWest Healthcare Alliance (TriWest) and its claims processor, Wisconsin Physicians Service Insurance Corp. (WPS) remind you that the Version 5010 transaction standards have different requirements than those of Version 4010 and 4010A. There are a few things to keep in mind for processing your Version 5010 claims, which should help avoid unnecessary rejections:

• ZIP Code: You need to include a complete 9-digit ZIP code for the billing provider and service facility location. You should work with your vendor to make sure that your system captures the full 9-digit ZIP. 
• Billing Provider Address: You need to use a physical address for your Billing Provider Address. Version 5010 does not allow for use of a PO Box address for either professional or institutional claim formats. However, you can still use a P.O. Box as your address for payments and correspondence from payers as long as you report this location as a pay-to address.
• National Provider Identifier (NPI): You were previously allowed to report an Employer’s Identification Number (Tax ID) or Social Security number (SSN) as a primary identifier for the billing provider. For Version 5010 claims, however, you are only allowed to report an NPI as a primary identifier. 

Providers are strongly encouraged to continue to take the necessary steps to complete the transition to Version 5010 as soon as possible. Network providers are required to submit claims electronically and need to be HIPAA 5010 compliant to avoid disruption of reimbursement.

TriWest has a dedicated web page for HIPAA 5010, which can be found at TriWest.com/Provider>EDI/ERA/EFT.

You may contact the WPS EDI team at 1-800-782-2680, Option #2, for additional information regarding 5010 conversion. 

Please visit the CMS 5010 Website for the latest news and resources to help you prepare!