What does it mean to be ready for HIPAA 5010?

The deadline for HIPAA 5010 - Jan. 1, 2012 - is approaching faster than many providers, payers and vendors would like. And, confusion abounds about what “readiness” means, says the Healthcare Billing & Management Association (HBMA).

To help provide some clarity, HBMA, a nonprofit educational resource and advocacy group representing third-party medical billers and billing professionals, submitted to the Centers for Medicare & Medicaid Services (CMS) earlier this month a standard definition of 5010 readiness.

“We began to notice that when someone said, ‘Oh, we’re ready,’ their meaning of ‘ready’ didn’t match the hearer’s definition of ‘ready,” said Bob Burleigh, co-chair of HBMA’s 5010/ICD-10 committee. “If the vendor is ready but there’s no insurer with whom they can exchange information because none of the insurers are ready then the word ‘ready’ doesn’t have much meaning.”

According to HBMA’s letter to CMS, "ready" means:

  • Providers are “ready” when they have successfully completed a production submission of claims (837) and received the associated remittance (835) for these claims in compliance with the 5010 specifications.
  • Payers are “ready” when they have successfully accepted a production submission of claims (837) and returned the associated remittance (835) for these claims in compliance with the 5010 specifications.

Provider readiness means:

  • All Practice Management System upgrades have been completed.
  • Confirmation of successful testing with direct submission carriers.
  • Confirmation of successful testing with clearinghouses.
  • Confirmation of successful production submission of claims.
  • Confirmation of successful retrieval of the claims’ associated remittance.

Payer readiness means:

  • All system upgrades have been loaded.
  • Confirmation of successful testing with direct submitting providers.
  • Confirmation of successful testing with clearinghouses.
  • Confirmation of successful acceptance of production claims (837) submission.
  • Confirmation of successful return of the claims’ associated remittance (835).

Even though the industry survived without a standard definition of “ready” during the 4010 transition, Burleigh believes a standardized definition now will remove a communication barrier, even with the compliance deadline just over two months away.

“Is it too late to have a standard definition? In fact, perhaps as we get closer to a live date when somebody says ‘ready’ then we’ll all know that ‘ready’ means ‘ready’ the way that we all mean it,” he said. “That gives us reason for comfort. If we don’t have a standard definition and everybody is saying ‘ready’ but what we find out when we pull the trigger is the lights go out -- not good,” said Burleigh.