HIPAA 5010 deadline is less than 60 days away

November 17, 2011

New technical standards for electronic claim filing and other electronic health-related transactions take effect on Jan. 1, 2012, the U.S. Centers for Medicare & Medicaid Services (CMS) is reminding health care practitioners.

Practitioners, over the coming days, can expect to receive notices from their software vendors, billing services, or claims clearinghouses regarding compliance with new Health Insurance Portability and Accountability Act (HIPAA) 5010 standards, according to the AOA Advocacy Group.

Practitioners who do not receive information regarding HIPAA 5010 updates from their software vendors in the near future should check with their vendor representatives, the AOA Advocacy Group emphasized.

Similarly, practitioners who retain billing services to file claims should check to make sure their software systems will be updated to meet HIPAA 5010 standards by the end of the year, the AOA Advocacy Group advices.

Once vendors or billing services have indicated their products and systems have been updated to meet 5010 standards, practitioners should test to make sure their claims will be filed smoothly and other transactions can be accomplished without problem, the CMS advises.

Claims filed in a manner not compliant with the new HIPAA 5010 standards will be rejected beginning New Year’s Day, the CMS emphasizes.

Federal law requires that beginning in 2012 health care-related transactions be conducted in a format meeting Accredited Standards Committee (ASC) X12 Version 5010 and National Council for Prescription Drug Programs (NCPDP) software standard.

HIPAA 5010-compliant software is designed to accommodate the use of ICD-10 billing codes, which the CMS plans to implement in October 2013.

For most optometrists who file claims in-house, compliance will be basically a matter of obtaining and installing HIPAA 5010 updates from their software vendors, the AOA Advocacy Group notes.

A spot survey of leading software vendors by AOA News earlier this year revealed most expected to make HIPAA 5010 software updates available to clients well before to Dec. 31, 2011. 

Medicare requires the use of electronic claims except in certain rare cases, the CMS noted. Paper claims submitted by practitioners through billing firms or clearinghouses are transcribed into electronic formats that will have to meet the new HIPAA 5010 standards.  Therefore it is important for even practitioners who file claims on paper to make sure their billings forms are prepared to meet the HIPAA 5010 standards, the CMS noted.

And all practitioners should test their claim filing and related systems before the of the year, the CMS emphasized.


Tests for HIPAA 5010 compliance should be conducted with all external trading partners, according to the CMS. That includes:

  • Billing services
  • Clearinghouses
  • Pharmacies
  • Entities responsible for coverage and benefit determinations, and
  • Payers

The CMS recommends practitioners initially test transactions that are conducted on a daily basis, such as:

  • Claims
  • Eligibility determinations
  • Remittances
  • Referral authorizations

After testing common, daily transactions, practitioners should test all remaining transactions to ensure that they are fully compliant, CMS officials said.

Nine-digit ZIP codes

In addition, some practitioners may have to make changes in their billing provider address.

To comply with HIPAA 5010 standards, each health care practice must report a physical street address in the “Provider Billing” address field.

Practices that wish to have payments delivered to a PO Box (or any address other than the Provider Billing address) can report that address in the “Pay-To Address” field.

While a PO Box address cannot be used as the practice’s street address, the PO Box may still be used for other claim addresses, such as a payer or patient address.

The HIPAA 5010 standards also require a nine-digit ZIP code be reported in the practice’s “Billing Provider” and “Service Facility Location” address fields. 

Practitioners can continue to use a five-digit ZIP code for the practice’s Pay-To Address, as well as for the “Subscriber,” “Patient,” “Payer” and all other address fields on the claim.

To be prepared, the CMS advices practitioners to review the ZIP code values now used for practice street and all service facility addresses to be sure they are valid nine-digit ZIP codes.

Practitioners can find their full nine-digit codes on the U.S. Postal Services Web site (www.usps.com).

The CMS offers extensive information on the HIPAA 5010 standards through the “5010 – DO” link on its Electronic Billing Standards Web page (www.cms.gov/electronicbillingeditransan) The CMS Web site now offers practitioners a “5010 Implementation Widget” (www.cms.gov/ICD10/03ICD-10andVersion5010ComplianceTimelines.asp).

The agency’s Medicare Learning Network library included a detailed article on the HIPAA 5010 standards (www.cms.gov/MLNMattersArticles/Downloads/SE1106.pdf).

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