Frequently Asked Questions

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By Topic: HIPAA Administrative Simplification

Does the National Provider identifier (NPI) Final Rule require individual health care providers who are als...
The NPI final rule states that NPI enumeration is the decision of the provider. Therefore, a provider who is an individu... (more)

Which Healthcare Provider Taxonomy Code(s) should be selected by medical students, interns, residents and f...
The Healthcare Provider Taxonomy Code set is a code set which may be used in certain standard transactions to indicate h... (more)

Are self-insured health plans required to get a Health Plan Identifier (HPID)?
A self-insured health plan must answer two questions to determine whether it must obtain an HPID.• Does it me... (more)

When must a health plan obtain a Health Plan Identifier (HPID)?
A controlling health plan (CHP) must obtain an HPID by November 5, 2014, unless it is a small health plan (annual receip... (more)

What are the Healthcare Provider Taxonomy Codes (HPTC)? Where may I obtain a copy of the codes?
The Healthcare Provider Taxonomy Codes (HPTC) are a HIPAA standard code set named in the implementation specificati... (more)

Who is eligible to receive an NPI?
The National Provider Identifier (NPI) was adopted and became effective May 23, 2007 as the standard unique health ident... (more)

If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the healt...
Yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of ... (more)

I have a Drug Enforcement Administration (DEA) Number. Do I need a National Provider Identifier (NPI) as w...
The NPI does not replace the function of the DEA Number, which is to identify the prescriber of a controlled or dangerou... (more)

What should a health care provider do if its National Plan and Provider Enumeration System (NPPES) data tha...
Health care providers who notice that their records are incorrect may update their information in NPPES at any time. The... (more)

How do I obtain a Health Plan Identifier (HPID)?
In order to enumerate (obtain an HPID), a health plan should:1. Create an account in the ... (more)

What types of business structures are considered organization health care providers and thus eligible for o...
The NPI final rule defines “organization health care providers” as providers who are not individuals (persons).... (more)

Which group health plans must obtain HPIDs?
A health plan (as defined in 45 CFR 160.103) includes a group health plan that provides, or pays the cost of, medical... (more)

What is the purpose of the National Provider Identifier (NPI), who must use it, and when?
The purpose of the National Provider Identifier (NPI) is to uniquely identify a health care provider in standard transac... (more)

What is the trace number segment (TRN Segment) that is required in an electronic funds transfer for health ...
The TRN Segment is a series of three data elements, plus one situational data element, that matches the TRN Segment in t... (more)

What is the difference between a health plan and a payer?
A health plan (as defined in ... (more)

Who enforces the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?
The Office of E-Health Standards and Services (OESS) within the Centers for Medicare & Medicaid Services (CMS) en... (more)

Will a health care provider’s National Provider Identifier (NPI) ever change?
The National Provider Identifier (NPI) is meant to be a lasting identifier, and is expected to remain unchanged even if ... (more)

Do medical students, interns, and residents need National Provider Identifiers (NPIs)?
All health care providers are eligible for NPIs and may apply for them. Because medical students, interns, residents, an... (more)

If an individual (i.e., a subscriber or a patient) uses his or her credit or debit card to pay for premiums...
The HIPAA standards must be used by “covered entities,” which are health plans, health care clearinghouses and healt... (more)

Since the January 1, 2014, compliance date for the operating rules for the health care electronic funds tra...
It is important that health care providers, their vendors, and health plans understand the electronic funds transfers... (more)

Are Flexible Spending Accounts (FSAs), Health Reimbursement Arrangements (HRAs), Health Savings Account (HS...
FSAs and HSAs are individual accounts directed by the consumer to pay health care costs.  As such, they do not r... (more)

Is there a complete list of non-specific procedure codes and if so, where can it be located?
Medicare has posted to its website the complete list of non-specific procedure codes.That list can be found ... (more)

What is the ACH Network?
The ACH Network is the Automated Clearing House (ACH) Network, one of the networks through which electronic funds transf... (more)

Is a health care provider required to obtain an NPI?
Yes. Under the NPI Final Rule (69 FR 3434), health care providers who are covered entities under HIPAA are required to o... (more)

Since the Health Plan and Other Entity Enumeration System (HPOES) require an NAIC number or Payer ID, how c...
Plans that do not have an NAIC number or Payer ID should enter “NOT APPLICABLE” in the required Payer ID field of... (more)

Are Fully-insured Group Health Plans exempt from the HPID requirement?
Fully-insured Group Health Plans are not exempt from the HPID requirements.  However, they are not required to obta... (more)

Can a health care provider continue to use other numbers besides the NPI to identify itself in standar...
No.  Only the National Provider Identifier (NPI) may be used for identification purposes for a covered health care ... (more)

Where are the error code meanings/descriptions for the error messages that will be returned on claims submi...
All error codes and their meanings/descriptions can be found on the WashingtonPublishing Website (http://www.wpc-e... (more)

What is meant by “certification of compliance” with HIPAA operating rules and standards?
Certification of compliance” refers to the requirements in section 1173(h) of the Social Security Act (which was added... (more)

What is WPC (Washington Publishing Company)?
Washington Publishing Company, Inc is a private company categorized under theA commercial Printing and Newspaper P... (more)

Are third-party administrators (TPA) representing self-insured plans required to obtain Health Plan Identif...
No.  All controlling health plans (CHPs) must acquire an HPID.  Many self-insured plans are controlling health... (more)

How can a health care provider apply for and obtain a National Provider Identifier (NPI)?
A health care provider may apply for an NPI in one of three ways: 1. Apply through a web-based application ... (more)

Who may apply for an HPID?
Health plans (including plan sponsors, trust administrators, or employers) are responsible for obtaining HPIDs.  Ho... (more)

Are small providers exempt from HIPAA?
No. The term “small providers” originates in the Administrative Simplification Compliance Act (ASCA), the law which ... (more)

How long will it take to get an NPI?
We cannot predict the amount of time it will take to obtain a National Provider Identifier (NPI) because several factors... (more)

Does an incorporated individual (e.g., a physician who has formed a corporation) whose corporation employs ...
An individual is eligible for only one NPI. In the above example, there are two health care providers: the physician a... (more)

Must providers who submit claims electronically comply with HIPAA if they submit claims on paper?
The HIPAA transactions commonly used by providers include claims, eligibility queries, claim status queries, and referra... (more)

I meet the definition of a health plan (as defined in 45 CFR 160.103) but do not conduct any standard trans...
Yes. The HPID final rule at ... (more)

What is a small health plan and what does my organization do if it does not have annual receipts?
A controlling health plan (CHP) must obtain an HPID by November 5, 2014, unless it is a small health plan (annual rec... (more)

Do I need a National Provider Identifier (NPI)?
All health care providers who are covered entities under the Health Insurance Portability and Accountability Act of 1996... (more)

If a health plan does not conduct a particular HIPAA transaction – for example, the health care claim sta...
If a covered entity is required to comply with the standards for a particular transaction, then the covered entity is... (more)

What is the purpose of the Other Entity Identifier (OEID) and who may apply for it?
The OEID is a standard identifier created for entities that need to identify themselves in HIPAA transactions, but do no... (more)

Can I use my Health Plan Identifier (HPID) for other business purposes?
Yes.  Health plans are free to use their HPIDs for any lawful business purpose.... (more)

Who is not eligible to apply for a National Provider Identifier (NPI)?
Any entity that does not meet the definition of a “health care provider” found at 45 CFR 160.103 is not eligible to ... (more)

Do fully-insured groups need to have their own Health Plan Identifier (HPID)?
Health Insurance Issuers (Carriers) are required to obtain HPIDs, as they are controlling health plans.  Fully-i... (more)

Can a health plan authorize a person to get a Health Plan Identifier (HPID) for the health plan?
Yes.  An authorized person is permitted to enroll the health plan in the Health Plan and Other Entity Enumeration S... (more)

When is an National Provider Identifier (NPI) entered in block 32.
Medicare does not require an National Provider Identifier (NPI) in block 32a nor a legacy number in 32b. If you are usin... (more)

What is the applicability of CORE “safe harbor"?
The Phase I CORE 153 Connectivity Rule, Version 1.0.0 provides business rules and guidelines for what CORE refers to ... (more)

Is CORE certification required for covered entities to be compliant with the CORE operating rules for eligi...
No. We do not require compliance with any aspect of CORE certification. CORE currently administers a voluntary certifica... (more)

Can I use my group practice's Employer Identification Number (EIN) instead of my National Provider Identifi...
No. On and after the compliance date of May 23, 2007, you are required to be identified as a health care provider in st... (more)

How do I know whether to use the National Drug Code (NDC), the Healthcare Common Procedural Coding System (...
The final rule adopting changes to the HIPAA Electronic Transactions and Code Set standards published in the Federal Reg... (more)

If a health care provider deactivates its National Provider Identifier (NPI), will its record still be in t...
No. Neither the downloadable file nor the query-only database will contain information about health care providers whose... (more)

What is the format of the National Provider Identifier (NPI)?
The National Provider Identifier (NPI) is all numeric and is 10 positions in length: the first 9 positions are the iden... (more)

What are the penalties for violations of the Health Insurance Portability and Accountability Act (HIPAA) re...
The HIPAA legislation permits civil monetary penalties of not more than $1.5 million per calendar year for a violat... (more)

What health care transactions are required to use the standards under HIPAA?
As required by HIPAA, on August 17, 2000 the Secretary of Health and Human Services adopted standards for the following ... (more)

When is the ASC X12 835 ( payment and remittance advice) standard required when conducting electronic funds...
The ASC (Accredited Standards Committee) X12 835 TR3 standard is required when a health plan transmits payment informati... (more)

If several pharmacies, each with their own National Provider Identifier (NPI), are owned by the same covere...
Payment and remittances for multiple pharmacies, each with their own NPIs, may be consolidated when the receiving entity... (more)

I do not submit healthcare claims to Medicare; do I need a National Provider Identifier (NPI)?
Yes. NPIs are required by the NPI Final Rule to be used to identify health care providers in HIPAA standard transactions... (more)

Can I send a compliant claim to a secondary payer and bypass the primary payer when the primary payer does ...
The American Standards Committee (ASC) X12 Version 5010 837 professional claim standard supports filing a claim to a sec... (more)

What do health plans have to do to comply with the health care electronic funds transfers (EFT) standards a...
As of January 1, 2014, health plans must use the CCD+Addenda as the format that they send to their bank to initiate an E... (more)

Do the CAQH CORE Phase I and Phase II Operating Rules for the Eligibility for a Health Plan and Health Care...
No, the CAQH CORE Phase I and Phase II operating rules for the Eligibility for a Health Plan and a Health Care Cl... (more)

Does a health plan that uses a bank or clearinghouse to format its health care electronic funds transfer (E...
Yes. As of January 1, 2014, if a health plan uses a clearinghouse or financial institution to format non-standard dat... (more)

Can providers require both paper and electonic remittance advice (ERA) from a health plan?
Yes, according to the CAQH CORE EFT & ERA Operating Rule Set, providers can request both paper and electronic remitt... (more)

Will HIPAA covered entities be fined or forced to pay a civil money penalty if a complaint is filed against...
Civil money penalties ... (more)

Do the operating rules for eligibility for a health plan transaction adopted in July 2011 under the Afforda...
No. CMS did not adopt operating rules for e-prescribing transactions. E-prescribing is not an adopted HIPAA transaction.... (more)

Will it be difficult to download the downloadable file?
The initial downloadable Zip file, as well as each monthly update Zip file, is a compressed archive file that will conta... (more)

Are the health care electronic funds transfers (EFT) standards, adopted in the interim final rule Administr...
 Yes.  As of January 1, 2014, whenever a health plan transmits an electronic  health care claim paymen... (more)

Do I need a National Provider Identifier (NPI) to make changes to my Medicare enrollment information?
Yes, Medicare providers must provide their NPIs when making any changes to their Medicare enrollment information.... (more)

What do providers have to do to comply with the health care electronic funds transfers (EFT) standards adop...
There are no requirements in the January 10, 2012 interim final rule that apply directly to providers.  The heal... (more)

Where can providers find the current version of the 837 Institutional and 837 Professional edits spreadsheet?
The following link will direct you to find the current 837I and 837P Edit Spreadsheets (more)

How does the Version 5010 upgrade affect my transition to ICD-10?
Version 5010 supports both the ICD-9 and the ICD-10 code set structures.Unlike the previous Version 4010/4010A1,... (more)

When will CMS update the Certificate of Medical Necessity Forms to add National Provider Identifiers (NPIs)?
All CMS Certificate of Medical Necessity forms have been updated to accept the NPI. You can find these forms on the CMS ... (more)

How does the Centers for Medicare & Medicaid Services (CMS) handle a Health Insurance Portability and A...
Enforcement of the transactions and code sets and unique identifier standards of the Health Insurance Portability and Ac... (more)

What transactions does the "Version 5010" Final Rule (CMS-0009-F) for HIPAA standards include?
The Version 5010 final rule (CMS-0009-F) at 45 CFR Part 162, adopts new versions of the ASC X12 and NCPDP standards for ... (more)

Do I need a National Provider Identifier (NPI) to enroll in the Medicare Program?
Yes, an National Provider Identifier (NPI) must be included on the CMS-855 enrollment application.... (more)

How do I share my National Provider Identifier (NPI) with Medicare?
Please share your NPI with Medicare by submitting it, along with appropriate legacy identifiers, on Medicare claims.... (more)

Are there standard requirements for health plans when they use the ACH Network to pay health care claims vi...
Yes.  As of January 1, 2014, health plans must use the CCD+Addenda as the format that they send to their bank to... (more)

The HIPAA Transactions and Code Sets rule requires that medical data codes that are valid at the time healt...
For inpatient claims that span multiple service dates, the date of discharge is used as the date to determine valid medi... (more)

How do I file a Health Insurance Portability and Accountability Act (HIPAA) complaint about transactions an...
A HIPAA complaint about transactions, code sets or unique identifiers can be filed electronically through the use of the... (more)

How do I submit a Health Insurance Portability and Accountability Act (HIPAA) complaint in writing for poss...
Complaints may be submitted in writing to the Office of E-Health Standards & Services (OESS.) Written complaints ... (more)

How does the Small Business Administration definition change affect the HIPAA definition?
The Small Business Administration has changed its definition of a “small business concern” from an entity that recei... (more)

What is OESS’ policy regarding information collected during the complaint process?
The Office of E-Health Standards & Services (OESS) has specific policies that explain how personal information is... (more)

What are Companion Guides? Where do I get them?
Companion Guides are health plan-specific versions of the HIPAA-adopted standard Implementation Guides/TR3 Reports that ... (more)

Does compliance with HIPAA require the submission of the 999 Implementation Acknowledgement Transaction whe...
No. The 5010 271 Eligibility response TR3 Report (ASC X12N 005010X279), in Section 1.6 of the Front Matter states a requ... (more)

What is the relationship between an operating rule and a standard?
Operating rules support the adopted standards for health care transactions by fostering and enhancing uniform use of ... (more)

The Centers for Medicare & Medicaid Services (CMS) definition of small health plan states that they are...
The Office of Civil Rights has a ... (more)

Will small providers office with less than 10 employees who bill on paper forms need to transition to HIPAA...
No. Providers who are allowed to submit paper forms under an Administrative Simplification Compliance Act (ASCA) waiver ... (more)

Who is required to comply with the adopted operating rules for claims status and eligibility under the Affo...
All covered entities as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are required ... (more)

Do federal requirements pre-empt state requirements for compliance with the adopted operating rules for eli...
When a state requirement related to the eligibility for a health plan or health care claim status transactions is contra... (more)

Has a standard format for health plan companion guides been adopted for any of the adopted transaction stan...
Yes.  The interim final rule, “Administrative Simplification: Adoption of Operating Rules for Eligibility for ... (more)

Your website states that the National Provider Identifier (NPI) will replace legacy identifiers; what are t...
By “legacy identifiers,” we mean identification numbers that entities, such as health plans, have assigned to health... (more)

Will there be any direction related to loosening the requirement that the Billing Provider address must not...
ASC X12 has issued the following response regarding the Billing provider P.O. Box:"This issue isexplicitly a... (more)

If a health plan cannot be certain whether an individual will be covered for a particular claim or what the...
Health plans must comply with the adopted operating rules and standards for the eligibility for a health plan transac... (more)

Are HIPAA covered entities protected from complaints when they make disclosures to Quality Improvement Orga...
The Social Security Act provides certain ... (more)

In which version of the NACHA Operating Rules & Guidelines do I find the implementation specifications ...
The CCD+Addenda implementation specifications are detailed in the 2011 NACHA Operating Rules & Guidelines.  ... (more)

Where can I find the 277CA edits that the MACs will be using when they return the 277CA transaction?
Here is the link to the most current Part A and Part B edits spreadsheets: (more)

Do the HIPAA requirements for the eligibility for a health plan transaction and health care claims transact...
No, under the definition of "health plan" at 45 CFR 160.103, issuers of long-term care nursing home fixed indemnity poli... (more)

Where can I submit questions or find answers to specific technical questions regarding the X12 standard Imp...
Specific technical questions regarding the X12 Implementation Guides and TR3 Reports may be submitted through the ... (more)

Is a health plan or provider compliant with the HIPAA transactions and code sets regulations if a clearingh...
If a covered entity chooses to use a business associate to conduct transactions on its behalf, the covered entity mus... (more)

Does HETS accept batch 270s (multiple accounts submitted and answered later, without maintaining a connecti...
At this time, HETS 270/271 does not accept batch eligibility files. HETS is a real-time 270/271 Medicare eligibility... (more)

Are there any fields that will need to be adjusted when printing out paper claims or will this be taken car...
Your software vendor will be responsible for changes to your 1500 form print image files.... (more)

What is an operating rule for a transaction and how is it different from a transaction standard?
In the interim final rule, “Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health... (more)

If a health plan's product is not designed to require co-pays, deductibles, and/or co-insurance, is the hea...
Health plans must comply with the adopted operating rules and standards for the eligibility for a health plan transac... (more)

Do the HIPAA transaction requirements, including the operating rules, apply to transactions between a healt...
No, the HIPAA transaction requirements, including the operating rules, generally apply to electronic transactions betwee... (more)

Why did the upgrade to Version 5010 happen?
Version 5010 transaction standards offer improved standardization for administrative and clinical data.  ... (more)

Are there adopted operating rules for the retail pharmacy eligibility transaction?
No. The National Council for Prescription Drug Programs (NCPDP), Version D.0 Telecommunication standard provides enough ... (more)

Will I still be able to submit P.O. Boxes with the 5010 Implementation?
The address for the billing provider must be an actual street address in the 5010 version (2010AA loop, N301). A Post Of... (more)

Is DDE and PC ACE 5010 compliant?
DDE is 5010 compliant and the Medicare 'free billing' software (PC-ACE) is 5010 compliant.... (more)

What is ASC X12?
The Accredited Standards Committee X12 (also known as ASC X12), chartered by the American National Standards Institute m... (more)

What is the compliance date for the provisions in the Administrative Simplification:  Adoption of Stan...
January 1, 2014. ... (more)

Is it true that if you are a software vendor and each facility/provider has their own Submitter ID number t...
Software vendors are only required to test and be approved as a vendor by each MAC that processes customers' claims. Eac... (more)

Do I need to send in a 9 digit zip code in my files and if so, what are the requirements?
Yes, all billing providers must submit 9 digit zip codes in the 2010AA N403. Claims containing facility information will... (more)

What does the Medicare Fee or Service 90 Day Enforcement Discretionary period consist of?
Medicare Fee-for-Service (FFS) has experienced significant increases in 5010 production transactions during the last few... (more)

Who can file a Health Insurance Portability and Accountability Act (HIPAA) complaint for transactions code ...
Anyone may file a HIPAA related complaint with CMS. The individual or organization filing the complaint must be able to ... (more)

Where can I find FAQs related to the March 30, 2011 CMS-hosted Medicare FFS HIPAA Version 5010 national pro...
CMS has made available a 5010 "resource mailbox" to accept email questions during the 72-hour period surrounding a 5010 ... (more)

Is the approved vendor list maintained by CMS or each individual MAC?
The approved vendor list is maintained by the individual MACs. The approved vendor list can be located on the MACs w... (more)

Does 5010 only affect electronic billing and ifso, does the waiver we have to bill on paper allow us to byp...
HIPAA 5010 only affects electronic billing. Paper bills are not impacted.... (more)

Will the current reports I receive be affected with the Version 5010 implementation?
New ASC X12standard acknowledgement (999) and rejection transactions (TA1) will be utilized. These transactions will rep... (more)

For 5010 how do you report services provided outside of the practice location?
Providers who travel to other physician offices to see patients need to submit the Billing Provider information of the P... (more)

Does 5010 affect Durable Medical Equipment (DME) suppliers?
Yes, HIPAA Transaction and Code Sets Final rule applies to all providers who submit claims electronically. Please visit ... (more)

What is PC-ACE Pro32 and how do trading partners use it for Medicare billing in the 5010 format?
PC-Ace Pro32 is a "stand alone" software package that creates a patient database and allows your office to elect... (more)

Will I need to complete a new EDI Provider Enrollment form?
Providers who are currently enrolled to submit EDI transactions to Medicare will not have to submit a new EDI Pr... (more)

Will rejections continue tooccur for claims where situational edits exists for duplicate data?
CMS plans to remove this specific edit for duplicate data, as well as others like it. We have to officially document the... (more)

Where can I get answers to technical questions and help with implementing the ASC X12 5010 TR3 Reports, NCP...
For technical questions about the ASC X12 transactions and standards, the Accredited Standards Committee (ASC) X12 pr... (more)

How will 835 Electronic Remittance Advices testing take place?
MACs have the ability to set up a parallel system for 835s allowing production 4010 835s to come in as normal and also a... (more)

Will the screens in the Direct Data Entry (DDE) system change toreflect the different fields for version 50...
No. Medicare DDE is proprietary in nature. DDE isnot required to include all version 5010 837I data. No, Medicare DDE is... (more)

Who is the authoring entity for the operating rules for eligibility and claims status transactions?
The Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) is the... (more)

Will all MAC's use the same translators in their front end systems?
No, MACs are currently operating using three different translators.... (more)

Is there any way to get a test 835 files back based on our test submission?
Yes, trading partners can be set up to receive the production parallel 835s. Trading partners will receive thenormal 401... (more)

If a HIPAA covered entity received a HIPAA transaction in December of 2011, in Version 4010, but they did n...
After December 31, 2011, HIPAA covered entities could not use the X12 Versions 4010/4010A and the NCPDP Version 5.1 rega... (more)

Occurrence code 50 is not allowed to be used in Version 4010 (837 Institutional). Will this code be accepte...
Code 50 (Assessment Date) is effective January 1, 2011 per the NUBC manual and can only be used for 5010 claims (NUBC ma... (more)

Are there adopted operating rules for acknowledgements transactions?
No. While there are standards for acknowledgments, and these may be used on a voluntary basis between willing trading pa... (more)

Is the use of the e-prescribing transaction affected by the operating rules for eligibility transactions ad...
See revised FAQ# 7357.... (more)

I am a billing agency that enter claims in a software system then sends claims through a clearinghouse. Do...
Both are crucial steps to the 5010 transition. Contact your software vendor and clearinghouse to ensure they are complia... (more)

Where can I obtain a copy of the Version 5010 Implementation Guides (TR3)?
You may purchase a copy of the 5010 Implementation Guide at: http://store.... (more)

What is the average time frame for testing?
Testing is automated and is driven by the trading partner. Trading partners must assess that they meet the following CMS... (more)

Will the 5010 Version of PC Print be able to handle both 4010 and 5010?
The 5010 Version 4.0 of PC Print allows the end user to load and view either a 4010 or a 5010 835 X12 data files... (more)

What steps can I take now if I haven't upgraded to Version 5010?
If you haven't ... (more)

I use PC-Ace Pro-32, what changes will I have to make to my software for it to be Version 5010 compliant?
PC-Ace Pro32 users must keepup to date with the most current version of the software. Upgrades to the software can be fo... (more)

Will the MACs be able to accept a mix of 5010 and 4010 claims during the 90 day enforcement discretionary p...
Yes, MACs will be able to accept a mix of 5010 and 4010 claims during the 90 day non-enforcement period.... (more)

Have operating rules been adopted for all of the HIPAA transactions for which the Secretary has adopted a s...
No. Operating rules have been adopted so far for the eligibility for a health plan transaction and the health care claim... (more)

What is Version 5010?
This is an update to ASC X12 Version 4010/4010A1 standards for electronic administrative transactions (such as elig... (more)

If we have business in multiple jurisdictions, do we have to test with every MAC?
Yes, it is advised that you test will all MACs that you conduct business with.... (more)

When testing for 5010, do you submit new claims (production claims) or old claims?
Please note, if you are in test status you would not be submitting production claims. Therefore, it is your choice to su... (more)

Is dual submission of the 4010 and 5010 transactions allowed?
Yes. Dual submission of the 4010 and 5010 transactions will be allowed until March 31, 2012. Beginning April 1, 2012, on... (more)

How does a trading partner receive a 5010 835 test file?
Please contact your local MAC and let them know you are interested in receiving a test 835. They will then begin generat... (more)

Are new Medicare direct submitting providers only allowed to enroll using 5010 transactions?
Yes. Per Technical Direction Letter (TDL) 11464, beginning October 1, 2011, all new direct submitting trading partners a... (more)

Will submitters who have not tested 5010 be able to continue to submit 4010 claims after January 1st while ...
Submitters who have not tested will need to submit their transition plan within 30 calendar days of the date of the noti... (more)

Is Medicare going to release information about exactly what a compliance plan will look like for the 90 day...
Medicare will not specify the format of the compliance plan. Submitters should outline the steps they have taken and the... (more)

I am a PC-Ace user and enter my claims individually into the program. Do I need to do anything other than ...
Please contact your local MAC to obtain the current PC-Ace version to ensure you have the most updated software. Once yo... (more)

While conducting 4010 transactions, if thesubscriber and the patient are listed as self, then the ANSI logi...
For Medicare, the patient is always the subscriber. This has not changed from 4010A1 Medicare billing.... (more)

When the Paperwork (PWK) segment scheduled to be implemented?
At this time, the Paperwork (PWK) implementation has been delayed to approximately April 2012.... (more)

Does compliance with operating rules apply to HIPAA transactions conducted within the same corporate entity...
Yes. Covered entities must conduct standard transactions, which includes using the adopted operating rules, when transmi... (more)

Do the CORE operating rules for eligibility apply only to real time transactions?
No. The CORE operating rules apply to both real time and batch transactions as specified in each of the respective opera... (more)

If a state Medicaid agency does not have deductibles, but has “spend downs,” does it have to return the...
There are no HIPAA operating rules that address spend down amounts.... (more)

How is 5010 production status granted?
The MACs will grant production status to a trading partner following successful testing. Please contact your local M... (more)

Is Medicare Fee-For Service (FFS) making the HIPAA Implementation standards available at no cost?
The HIPAA standards for implementing theTransactions (e.g. Health care Claim, Eligibility or Retail Pharmacy claims) are... (more)

How soon after a claim file is transmitted should I expect the 277CA reports?
The receipt of the 277CA response is dependent on several factors such as size of the file submitted, time of day, weeke... (more)

Are all Medicare Administrative Contractors (MACs) accepting live HIPAA 5010 production claims?
Yes, all MACs are accepting HIPAA 5010 productions claims.... (more)

After a trading partner has successfully completed testing using the new5010version software, when and how ...
Please contact your local MAC. They will confirm your completion of 5010 testing and release youfor production s... (more)

What happens if I did not upgrade to HIPAA Version 5010?
Electronic transactions that do not use Version 5010 standards might not be processed and therefore, payments may b... (more)

What resources are available from CMS to help with Version 5010 implementation?
The CMS website has ... (more)

What should payers do to comply with Version 5010/D.0?
Payers should have successfully completed their 5010/D.0 testing and be collaborating with their trading partners on con... (more)

Is it only Medicare that isupgrading to version 5010?
No. The HIPAA standards, including the X12N Version 5010 standards are national standards and apply to your transactions... (more)

Can the current version ofPcAce be used for 4010 and5010 claims?
The current version of PcAce (released inOctober of 2011) can handle both 4010 and 5010 claims. Please note the ... (more)

What is Medicare doing to expedite the MACs progress in pushing Submitters into production?
Medicare is lightening the MACs role in the test process (as CMS did for 4010 implementation) so that the provid... (more)

What will happen if submitters don't submit a test plan related to the 90-day enforcement discretionary per...
If no transition plan issubmitted, Medicare Fee-for-Service may direct the MACs to reject 4010 claims. The MACs have not... (more)

What is Version D.0?
Version D.0 is the updated version of the NCPDP standards for pharmacy transactions that replaces Version 5.1. NCPDP ... (more)

What should providers do to verify compliance with Version 5010 and D.0?
Providers who use practice management and other applicable software programs should make sure that their software fea... (more)

Will the 5010 Version of PC Print be able to handle both 4010 and 5010?
The 5010 Version 4.0 of PC Print allows the end user to load and view either a 4010 or a 5010 835 X12 data files.... (more)