5010 Readiness

MD On-Line has committed to having our internal systems, supporting business processes, policies and procedures successfully meet the implementation standards and deadlines mandated without interruption to our Customers. We have developed conversion procedures that will enable you to continue to submit in your current format and will also be able to accept your claims in any upgrade format.

MD On-Line is implementing conversion plans for the legacy formats that we currently receive from providers in preparation for 5010. We currently accept non-standard transactions while meeting the HIPAA compliant 4010A1 standards, and we will continue to do so when 5010 is implemented. MD On-Line will provide the necessary conversions on non-standard files to accommodate the needs of our providers trading partners and payer partners.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards that covered entities (health plans, health care clearinghouses, and certain health care providers) must use when electronically conducting certain health care administrative transactions, such as claims, remittance, eligibility, and claims status requests and responses.

The current versions of the standards (the Accredited Standards Committee X12 Version 4010/4010A1 for health care transactions and the National Council for Prescription Drug Programs [NCPDP] Version 5.1 for pharmacy transactions) used in these health care transactions lack certain functionality required by the health care industry. Therefore, it is necessary for providers to prepare for new standards in order to continue submitting claims electronically.

MD On-Line has been following the evolution of the Administrative Simplification provisions of HIPAA since its inception in 1996. We are committed to delivering excellent service and to adopting administrative simplifications for HIPAA transactions and code sets; including compliance with and support of the HIPAA 5010.

Our implementation strategy to integrate the X12 version 5010 is underway as we support the improved data content and transactions consistency offered by this standard.

We have established internal multi-functional teams throughout our company, to research, assess systems, perform a gap analysis, review business processes and forms, and educate MD On-Line staff on changes associated with the migration to 5010.

By December 31, 2010, MD On-Line plans to begin testing of the Version 5010 transactions with 4010A1 trading partners.

During 2011, MD On-Line will continue testing with Trading Partners and utilize both standards, 4010A1 and 5010 based upon Customer and Trading Partner readiness - as permitted by the final rule.

On January 1, 2012, MD On-Line will comply with using Version 5010 exclusively for HIPAA transactions.

What should I do to prepare for the 4010 to 5010 transition?

We will soon be providing additional information tailored to your current submission method about how to test with the HIPAA 5010 transactions with MD On-Line. In the interim, we suggest you begin a detailed analysis of your current submission method and evaluate potential changes to your submission format.

Why is the industry changing to 5010?

Version 5010 improvements in front matter, technical, structural, and data content, include the following:

• Standardizes the business information related to the transaction;
• Is more specific in defining what data needs to be collected and transmitted;
• Accommodates the reporting of clinical data, such as ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes;
• Distinguishes between principal diagnosis, admitting diagnosis, external cause of injury, and patient reason for visit codes;
• Supports monitoring of certain illness mortality rates, outcomes for specific treatment options, some hospital length of stays, and clinical reasons for care; and
• Addresses currently unmet business needs, such as an indicator on institutional claims for conditions that were "present on admission."

Who needs to upgrade to 5010?

HIPAA covered entities affected by the transition to Versions 5010 and D.0 include the following:

• Providers, such as physicians, alternate site providers, rehabilitation clinics, and hospitals;
• Health plans;
• Health care clearinghouses; and
• Business associates that use the affected transactions, such as billing/service agents and vendors.

5010 Transition - Important Dates