HIPAA Enforcement Approaches for Electronic Claims, Version 5010

In early 2009, the Department of Health and Human Services (HHS) published the final rule that requires the implementation of HIPAA Accredited Standards Committee (ASC) X12 version 5010 for electronic claims, referrals, enrollment, patient eligibility inquiries, coordination of benefits (COB), and remittance advices.  This replaces version 4010Ai.  The new version is required to allow the transition in 2013 from ICD-9-CM to ICD-10 coding.  In order to ensure the submission of electronic claims, healthcare providers have been working to prepare for the transition.

Covered entities were required to comply beginning January 1, 2012 (small plans have until January 1, 2013, to comply with the NCPDP Medicaid Subrogation 3.0 standard).  Covered entities include healthcare providers, health plans, and healthcare clearinghouses.

The Center for Medicare & Medicaid Services (CMS) Office of E-Health Standards and Services (OESS) will enforce the compliance standards.  In November 2011, CMS announced, “While enforcement action will not be taken (until March 31, 2012), OESS will continue to accept complaints associated with compliance with Version 5010, NCPDP D.0 and NCPDP 3.0 transaction standards during the 90-day period. . . .  If requested by OESS, covered entities that are the subject of complaints (known as ‘filed-against entities’) must produce evidence of either compliance or a good faith effort to become compliant with the new HIPAA [version] standards during the 90-day period.”  You can access the announcement here.

Unless extended again, enforcement of compliance ASC X12 v5010 will begin midnight March 31, 2012.


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About Andrew (Andy) Wampler

For over a decade, I have provided legal services to businesses and individuals in Northeast Tennessee. I spend time litigating breaches of contract, medical malpractice, and commercial disputes and have worked on a number of transactions. I also advise businesses, working much of my time on healthcare and employment matters.

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