Understanding HIPAA 5010

In January 2009, the HHS or the U..S. Department of Health and Human Services had released two final rules as a part of HIPAA (Health Insurance Portability and Accountability Act of 1996) with a view to upgrade the existing standards set for electronic healthcare transactions. As a result, the X12 Version 5010 HIPAA Transactions Standards & Code Sets was created. The HIPAA 5010 is now mandated for all covered entities, i.e. all healthcare entities, clearinghouses and associated business partners handling patient/healthcare data.

Decoding HIPAA 5010
Version X12 HIPAA 5010 is meant to replace the conventional version of the HIPAA guidelines or the 4010A1 Version HIPAA Transactions Standards & Code Sets. HIPAA 5010 was conceptualized since the existing standards set for regulating electronic transactions in the healthcare industry were increasingly getting outdated. Many stipulations included in the original HIPAA seemed didn’t seem to be practical for the covered entities that was already struggling to adopt the HIPAA standards in their entirety. X12 Version HIPAA 5010 is committed towards improving the systems supporting healthcare practices, policies and processes and the implementation standards defined by HHS.

The X12 Version of HIPAA 5010 Transactions Standards & Codes is essentially a more comprehensive/detailed form of HIPAA Transaction Standards. This is why the X12 Version 5010 HIPAA Standards & Code is also referred to as 'Enhanced HIPAA Transaction Standards' by many of the insurance carriers. HIPAA 5010 has already received the highest level of official recognition in the US health industry after being endorsed by the HHS. Since HIPAA regulations are applicable to all types of Covered Entities, the 5010 update is equally applicable to group health plans too, i.e. both self-insured and fully-insured health plans.

Impact of HIPAA 5010
The HIPAA 5010 seeks to impact some aspects of HIPAA regulations in a more significant manner. These include health information processing aspects like:
• Claims & Encounters—including medical claims from dental, professional and institutional entities
• Issues related to Enrollment in healthcare stimulus plans
• Issues related to Authorization, Request, Referral & Response
• Issuing of Payment/Remittance Advices
• Payment of Premiums
• Eligibility Request
• Inquiries related to status of submitted Claims & their Response

Updating to 5010 HIPAA Standards is not Difficult
The integration of X12 Version 5010 will not put forth any major financial or technical issues and will significantly improve integrity of data (patient information) storage and sharing systems. Covered Entities necessarily do not need to establish separate clearinghouses for achieving compliance with HIPAA 5010. The adoption of X12 Version 5010 HIPAA is already underway with many of the EPMOs, i.e. Enterprise Program Management Offices, suggesting changes to help covered entities update their healthcare processing standards to meet HIPAA 5010 guidelines. Please note that EPMOs were established with the primary goal of overseeing HIPAA Compliance and thus, their involvement in ensuring 5010 HIPAA compliance is an expected outcome. A notable example in this niche is that of leading healthcare insurance providers like Anthem Blue Cross that have been proactive in moving towards HIPAA 5010 compliance through the effective use of EPMOs.