Let’s discuss the basics of HIPAA 5010. Original site for information is http://www.emdeon.com/5010/. The information on this site is presented in a simple easy to understand manner.

HIPAA 5010 expands HIPAA regulation to include electronic transmission of healthcare transactions, including eligibility, claim status, referrals, claims, and remittances. Covered entities are required to comply. Covered entities include: Physicians, Clearinghouses, Hospitals, Pharmacies, Payers, and Dentists. Software vendors all also expected to comply.

The following transactions are specifically cited in the new standards:

  1. Health Care Eligibility Benefit Inquiry and Response
  2. Health Care Claim Status Request and Response
  3. Health Care Services Request for Review and Response
  4. Health Care Services Notification and Acknowledgement
  5. Payroll Deduction and Other Group Premium Payment for Insurance Products
  6. Benefit Enrollment and Maintenance
  7. Health Care Claim: Payment/Advice
  8. Health Care Claim: Professional
  9. Health Care Claim: Institutional
  10. Health Care Claim: Dental
    1. NCPDP Pharmacy Claim

      A cartoon depiction of moses with two headstones. One saying HIPAA and the other saying HITCH. Learn the Basics of HIPAA 5010 and HIPAA in this blog.

      Basics of HIPAA 5010 and HIPAA

The main reasons for the upgrade to HIPAA 5010 are:

  1. The ability to support new-use cases brought forward by the industry
  2. Clarification of usage to remove ambiguity
  3. Consistency across transactions
  4. Support of the NPI regulation
  5. Removal of data content that are no longer used

By 2016, the healthcare industry will be required  to achieve compliance with the following mandates form both HIPAA and the Affordable Care Act.

  1. ASC X12 version 5010 and NCPDO D.O.
  2. ICD-10
  3. Eligibility and Claim Status Operating Rules
  4. Health Plan ID (HPID)
  5. EFT and ERA Operating Rules
  6. Claims Attachment Rules
  7. Claims, Enrollment, Authorizations Operating Rules

Following is a compliance timeline from 2009-2016:


  1. 3/17/09 Modifications to code sets ICD-10 Effective
  2. 3/17/09 Modifications to transactions (5010) Effective


  1. 6/30/11 Eligibility and Claim Status Operating Rules Effective


  1. 1/1/12 5010 Transactions Enforcement 6/30
  2. 1/10/12 EFT Standards Effective
  3. 7/1/12 EFT/ERA Operating Rules Effective
  4. 10/1/12 Health Plan ID Prescriber Modifications to NPI Effective


  1. 1/1/13 Eligibility and Claim Status Operating Rules Compliance
  2. 4/7/13 Prescriber Modifications to NPI Compliance
  3. 12/31/13 Eligibility, Claim Status, EFT, ERA Health Plan Certification


  1. 1/1/14 Claims Attachment Rules Effective
  2. 1/1/14 ERA/EFT Standard and Operating Rule Compliance
  3. 1/1/14 Claims Enrollment, Authorization Premium Payment, Operating Rules Effective
  4. 10/1/14 Health Plan ID Compliance


  1. 12/31/15 Claims, Enrollment, Attachments, Premium Payment, Referral Health Plan Certification


  1. 1/1/16 Claims, Enrollment, Authorizations Operating Rules Compliance
  2. 1/1/16 Claims Attachment Rules Compliance

BHM Healthcare Solutions is a healthcare consulting company dedicated to providing healthcare management consulting services. One of our areas of specialty is HIPAA compliance. If you are in need of assistance with HIPAA issues in particular, please visit our HIPAA compliance page and contact us at 1-888-831-1171.