5010 Questions and Answers

Updated: June 15, 2011

Introduction

What is 5010?

The updated X12 Version 5010 of the HIPAA transaction standards represents substantial technical and operational improvements that respond to industry business needs and requests. With the transition to Version 5010 the industry will be better equipped to move toward an electronic health information environment via the increased and improved use of Electronic Data Interchange (EDI). The compliance date for Version 5010 is January 1, 2012.

The use of Version 5010 supports ICD-10-CM (Clinical Modification) for diagnosis and ICD-10-PCS (Procedure Coding System) for inpatient hospital procedure code sets that have been adopted in a separate regulation. The compliance date for ICD-10 conversion is October 13, 2013.

ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service, and inpatient claims with dates of discharge on and after October 1, 2013. Otherwise, your claims and other transactions may be rejected, and you will need to resubmit them with the ICD-10 codes. This could result in delays and may impact your reimbursements, so it is important to start now to prepare for the changeover to ICD-10 codes. This change does not affect CPT coding for outpatient procedures.

Who is Affected by the change to 5010?

The legislation mandates industry-wide migration from the current 4010A1 version to a newly established 5010 version, for health information transactions governed under HIPAA. All HIPAA covered entities should begin planning for implementation of Version 5010. Entities such as:

  • Hospitals
  • Physicians
  • Dentist
  • Payers
  • Vendors
  • Billing Services
  • Laboratories
  • Clearinghouses

Clearinghouse and software vendors should start developing compliant products to ensure availability for the industry to test and implement. Vendors are critical in terms of providing the software and applications to make the transactions possible and to allow for early testing between trading partners.

The rule requires that internal testing be completed by December 31, 2010. This means that software and hardware changes in all systems must be in place as soon as possible in order to fully test each entity’s ability to send, receive and process standard transactions.

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Affected Transactions

What transactions are affected?

The following transactions are included in the 5010 Final Rule:

  • 837 - Health Care Claims for professional, institutional and Dental
  • 835 - Health Care Remittance Advice
  • 270/271 - Health Plan Eligibility Inquiry and Response
  • 276/277 - Health Care Claim Status Request and Response
  • 278 - Health Care Services - Request for Review and Response
  • 820 - Health Plan Premium Payment
  • 834 - Health Plan Enrollment and Disenrollment
  • NCPDP D.0 - Retail Pharmacy Drug Claims

For a complete list follow this link and go to Table 1 at the bottom of Page 2: HHS Final Rules and Regulations

What are the key changes from version 4010A1 to 5010?

The key changes fall into these four basic categories:

  • Front Matter
  • The front matter, or preface, of the Technical Report Type 3 (TR3) provides improved instructional information, such as an overview of the scope and implementation purpose for the transaction. These changes are intended to address content presentation in order to make the data more uniform and standard across all transactions.
  • Technical Improvements:
  • The technical improvements are intended to streamline information exchange. One of the fundamental improvements is the organization of data content for all guides making the usage consistent between transactions.
  • Generic descriptions have been replaced with specific descriptions to reduce or remove redundancy in repeat counts within loops and segments.
  • Structural Changes:
  • The structural changes consist of the restructuring of loops, such as loops being added, deleted, modified or repositioned. The structural changes also impact segments and data elements.
  • Data Content:
  • The data content changes provide clarification of usage to better support the intent of the data. The primary goal of this change is to reduce the redundancy and provide more detailed information across transactions.
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Technical Information

What is a TR3?

The TR3, also known as the Technical Report Type 3, is a document that explains the technical implementation and use of a transaction standard. Each transaction has an associated TR3. The TR3 is formerly known as the Implementation Guide or IG with v.4010.

Where can I find more information about the implementation of 5010?

For more information the Centers for Medicaid and Medicare Services (CMS) has provided Fact Sheets and Check List to assist in the transition to 5010. Please visit the CMS Educational Center at: http://www.cms.gov/Versions5010andD0/40_Educational_Resources.asp

Where can I purchase the 5010 X12 Implementation Guide

The implementation guides for Version 5010 are available for purchase at these two sites: X12.org - http://store.x12.org/. or from WPC - http://www.wpc-edi.com/

Where can I download the Industry Standard GAP Analysis for X12 Transactions.

The documents are available for download in Microsoft Excel and PDF formats at the CMS web site.

Go to: http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp

What is an Errata?

The Errata is created by ASC X12 to resolve impediments to implementation identified after the publication of the TR3s. Similar to the Addendum for v.4010, the Errata only contains pages that have changes. Changes are identified using techniques such as added text and arrows pointing to the location the text would have appeared if it was present in the original document.

Where can I download the Errata?

The Errata documents are available to download at no cost to owners of the TR3s by clicking here.

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Capario Transition

What is Capario’s Transition Schedule?

Capario’s transition to version 5010 will meet the guidelines established by CMS.

  • 2009-2010 - Level 1 Activities
    • Gap Analysis
    • Design
    • Development
  • 2010 - Level 1 Testing
    • Internal Testing
    • Regression
    • End to End
  • 2011- 2012 - Level 2 Testing
    • External Testing with Submitters
    • External Testing with Payers
    • Dual Processing
  • January 1, 2012 - 5010 Production
    • Claims
    • ERA
    • Eligibility
    • Claim Status
What formats will be supported after Jan. 1, 2012?

Capario will continue to support the following legacy formats and provide translation services, as needed, to be 5010 compliant:

  • ASC v. 4010A1
  • CMS 1500 print image
  • NSF 2.0
  • NSF 3.01
  • Proprietary formats (Medicare Crossover Only)
What formats willnotbe supported after Jan. 1, 2012?

Capario will no longer accept the following legacy formats after January 1, 2012:

  • NSF 4.0 (Capario proprietary format)
  • ASC v. 3051
  • Proprietary

Customers using these formats will be contacted in Q4 2010 to discuss a migration plan to a supported format.

What if I am not ready to submit 5010 transactions on January 1, 2012? Can we still use Capario as a clearinghouse?

Yes. Capario will offer dual processing in which we will have the ability to “up convert” legacy inbound formats (4010A1, NSF 2.0, NSF 3.01, CMS 1500 Print Image) in order to deliver outbound 5010 transactions to those receivers who are ready.

In addition Capario will “down convert” inbound 5010 transactions to outbound legacy formats for those receivers who are not ready.

This process will allow providers/vendors to submit in their preferred format, and allow payers to receive in their preferred format.

Will Capario process 4010A1 and 5010 transactions during the transition period? Is there a cut off date for 4010A1?

Capario will accept Versions 4010A1 and 5010 during the transition period and beyond. At this time, there areno plans to discontinue Version 4010A1.

Capario will continue to accept Version 4010A1 after the compliance date of January 1, 2012 and will provide translation services as needed for 5010 compliance.

Will Capario return 835s in the same format as the inbound 837 claim?

Customers can designate if they want to receive their 835s in the 4010 or 5010 format. This allows customers the flexibility and time to test their posting and processing of remittance transactions, independent of the claim transaction. The customers can tell us what 835 format they want to receive.

Will Capario support additional EDI reports with the transition to 5010?

Yes. In addition to our current EDI reports, Capario will support the new 999 Implementation Acknowledgement for Health Care Insurance (ASC X12C/005010X231) and the 277CA Health Care Claim Acknowledgments (ASC X12/005010X214).

Will Capario offer the 997 file level acknowledgement to 5010 submitters?

Yes. Capario will offer the 997 report to 5010 submitters.

Will Capario continue to support 275 - Healthcare?

Yes. Capario will continue to support the 275 - Healthcare attachment.

How will Capario determine the format sent to the payer during the 2011 transition period?

Each payer will determine the effective date in which they will begin receiving the new 5010 format. Capario will continue to accept legacy formats (4010A1, NSF 2.0, NSF 3.0 and CMS 1500 Print Image) and will “up convert” or “down convert” to the payer’s preferred format.

For paired transactions (270/271 Eligibility and Benefits Inquiry and Response, 276/277 Claim Status Inquiry and Response, etc.), due to Capario’s ability to “up convert” and “down convert” the response returned to the submitter will be in the same version as the initial inbound inquiry transaction.

How will Capario handle paper claims?

Capario will continue to offer claims printing services regardless of the inbound format submitted by our customers.

Will Capario continue to offer the “immediate” report option for NSF 3.01 and Print Image submitters?

Capario will continue to offer the “immediate” report option to NSF 3.01 and Print Image submitters however, due to the fact that payers are going to implement 5010 on different timelines, submitters will receive a separate REC file for the claims processed to 4010 payers and for payers that have migrated to 5010. The option to receive a single REC file per day for 3.01 and Print Image submitters will no longer be available.

Will Capario implement the changes identified in the Errata?

Yes. Capario will comply with the standards outlined in the TR3s and the changes that are identified in the Errata.

Will Capario offer training and/or information sessions on their 5010 transition plans? If so, how do I sign up?

Yes, Capario will offer training and/or informational sessions on our 5010 transition plan. Sign-up information will be announced in our News Letter.

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Capario Testing for Submitters

When will Capario begin external testing with 5010 transactions?

Capario will begin external testing with customers in January 2011. For additional information regarding 5010 testing and timelines per transaction please review Capario’s Companion Guide.

Will Capario test 5010 with all receivers?

Capario has established a testing process for payers/receivers that choose to participate in Level 2 External Testing with Capario.

For payers/receivers that would like to test with Capario please contact our Payer Services Team at 5010payer@capario.com.

Will Capario test 5010 with all submitters?

Since Capario will continue to accept Version 4010A1 not all submitters will transition to Version 5010 immediately. For those submitters that are ready to transition, Capario requires all Vendors to test prior to production meaning individual user testing is not mandatory, but is strongly encouraged.

To engage Capario for vendor or submitter testing please contact your Account Manager, our Partner Services department at partner@capario.com or our EDI Department at EDI@Capario.com

Will Capario provide a dedicated testing environment for 5010 testing?

Yes, Capario will provide a dedicated testing tool for customers to complete their 5010 transaction testing. For additional information regarding the testing tool please review the Capario’s Companion Guide.

Will Capario test and implement all 5010 transaction types at one time?

Capario will conduct Level 1 Internal Testing for all transactions in 2010. Capario will be prepared for Level 2 External Testing and 5010 production for all transaction in 2011.

Will Capario provide 835’s back to our customers as part of testing for 5010?

No, Capario does not have the ability to generate 835’s. 835’s are pass-thru from the payer. However, Capario will have the ability to convert 835’s received from the payers in the 4010A1 to a 5010 835 during testing.

How many test cycles will Capario require?

No minimal or maximum requirements.

How many claims will Capario require in each test file?

No minimum amount. Test file can not exceed 500 claims.

How often should test files be sent?

Your option. Capario will offer a self-service testing tool so testing can be done at your convenience.

Will Capario supply a companion guide per transaction type? If so when?

Although Capario will comply with the TR3 documents, we posted our Companion Guide on December 6th. It provides information regarding testing, timelines, production, and much more for all transaction types. Capario’s Companion Guide.

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Capario Testing for Payers

What is Capario’s process when a payer is ready to begin 5010 Payer Testing?

The process for 5010 Payer Testing is in our 5010 Companion Guide. Click Here.

What unique steps will Capario take when up/down converting claims prior to sending them to the payer?

These unique steps are covered in our Translation Business Rules. Click Here.

5010 Production

How will customers be notified of approval to move to 5010?

Readiness is based on testing results. Test results will be available via the self-testing tool. After successful testing simply begin sending 5010 production transactions, but not before April 2011. Please review Capario’s Companion Guide. for additional information regarding the transition to 5010.

When will Capario move to production with 5010?

Due to recent changes by CMS, which are outlined in the Errata, Capario’s 5010 production date is scheduled for April 2011.

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Enrollment

Will enrollment or re-enrollment be required for 5010?

Based on each payer's requirements for enrollment or re-enrollment Capario will notify providers by Customer Notification. In addition Capario will work with payers to determine if we can re-enroll providers as an automatic mass upload so that the transition is seamless to our submitters.

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Formatting

Due to the differences in data content between the 4010 and 5010 formats, what are Capario’s plans when “up” and “down” converting data?

Capario has developed “Translation Business Rules” for each transaction. These Translation Business Rules will provide detailed explanations, primarily for developers, on how Capario will bridge the data content differences between the 4010 and 5010 format. Click here - Capario Resource Center

Can we use the same submitter and receiver ID’s we are using today or will we need to change them for 5010?

Submitters will use their existing submitters id’s during the transition period. Both 4010 and 5010 will be accepted under the existing submitter/client account.

Can we use the same file delimiters as we are using today?

Yes, Capario will support all 837 submitted file delimiters as outlined in the TR3.

Does Capario have requirements for file naming conventions? Will the file names used for 5010 need to be different from 4010A1?

No, we will have no restrictions on file naming convention. Our engine will determine version from GS08.

Will Capario require our customers to build any specific edits to support Capario's payers for 5010?

No, Capario will be building our 5010 payer validation based on the Payer’s Companion Guides.

Will Capario's payer list identify the payers approved to move to 5010?

Yes, our payer list will identify the payers that have moved to 5010.

Will Capario accept v. 4010 and v. 5010 from the same submitter?

Yes. Capario will accept both formats from the same submitter but will require separate files. For example, if the submitters is going to send both formats Capario will expect to receive an inbound 4010 file and an inbound 5010 file. The formats should not be combined into one single file.

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Transmission/Connectivity

Will Capario require new connectivity methods?

No, our connectivity options will not change.

Will the same delivery method be used for 4010A1 and 5010?

Yes, same delivery method may be used.

Does the timing change for claim submission or for retrieval of reports change for 5010?

The timing does not change so no changes are needed.

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Contact Capario

How do I contact Capario for Vendor testing?

To engage Capario for vendor testing please contact your Account Manager or our Partner Services department at partner@capario.com

How do I contact Capario for Payer testing?

For payers/receivers that would like to test with Capario please contact our Payer Services Team at 5010payer@capario.com.

How do I contact Capario for Provider testing?

To engage Capario for provider testing please contact your Account Manager or our EDI department at EDI@capario.com

How do I contact Capario for general 5010 questions?
For 5010 questions send them to us at: 5010@capario.com
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Back to Capario's 5010 Page

Does this page need revision? If so please send an email to: scodon@capario.com.