HIPAA Transaction Standards

Transactions are electronics exchanges involving the transfer of healthcare information between two parties for specific purposes—such as a healthcare provider submitting medical claims to a health plan for payment.

HIPAA adopted certain standard transactions for electronic data interchange (EDI) for the transmission of healthcare data. These transactions are:

• Claims and encounter information
• Payment and remittance advice
• Claims status, eligibility, enrollment, and disenrollment
• Referrals and authorizations
• Premium payment

Under HIPAA, if a covered entity conducts one of the adopted transactions, they must comply with the adopted standard, adhering to the content and format requirements specified in the HIPAA standards. The current transaction standard is 4010A1.

HIPAA Transactions: 5010

On January 16, 2009, HHS published a requirement to adopt X12 Version 5010 and NCPDP Version D.0 for HIPAA transactions (replacing the 4010A1 standard). In this rule, HHS also adopts a new standard for Medicaid subrogation for pharmacy claims, known as NCPDP Version 3.0. For Version 5010 (for some healthcare transactions) and Version D.0 (for pharmacy transactions), the compliance date for all covered entities is January 1, 2012. January 1, 2012 is also the compliance date for the Medicaid subrogation standard, except for small health plans, which have until January 1, 2013, to become compliant. This rule can be reviewed in its entirety from the GPO e-docket (See Health and Human Services Department).

Version 5010 accommodates the ICD-10-CM/PCS code sets, and has an earlier compliance date than ICD-10-CM/PCS in order to ensure adequate testing time for the industry. The two rules implementing 5010 and ICD-10-CM/PCS apply to all HIPAA-covered entities, including health plans, healthcare clearinghouses, and certain healthcare providers. The latest CMS information about 5010 can be found on the CMS's Transactions and Code Sets site.

AHIMA Version 5010 Resources:

• Analysis of the Final Rule, January 16, 2009, Health Insurance Reform; Modifications to the Health Insurance Portability and Accountability Act (HIPAA) Electronic Transaction Standards
• Why 5010 is needed*
• Preparing for 5010: Internal Testing of HIPAA Transaction Upgrades Recommended by December 31
• The Breach Notification and 5010 Deadlines: Regulations Outline new Deadlines for Breach Notification and 5010 Standards Testing*
• Playing Catch-up on 5010
• Tracking the Industry's Progress: AHIMA Survey on ICD-10 and 5010 Compliance*
• Simplification at Last? HHS Rolls Out Operating Rules for HIPAA Transactions

*Available to AHIMA members only (Not a member? Join now).

External Resources

• American Medical Association: Version 5010 Electronic Administrative Transactions 
• Center for Medicare and Medicaid (CMS): FAQ's Versions 5010 and D.0 Basics
• Center for Medicare and Medicaid (CMS): 5010 - D.0