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5010

Final Rule published in the Federal Register, January 16, 2009

X12 5010 Transactions replace the 4010[A1] Versions.


NCPDP 5.1 and 1.1 replaced by D.0 and 1.2
1/1/2012

Impacts/Changes to the transactions:


System:
• Identify the changes in data elements [size, requirement, usage notes]
• Consider options for usage a new/revised data elements
• Inventory and identify opportunities for proprietary file elimination

Business:
• Added elements needed/wanted in adjudication
• Impact of missing elements
• Impact of changes in usage notes
• Impact of changes in transaction structures within the transaction and across
transactions [i.e., if payment must be identified at the line level on the 835 –
how do you do that when AHCCCS pays an overall tier at the header level?]
• Identify all the documentation that will need to be updated

Transactions
II. Provisions of the Proposed Rule
a. Proposed adoption of Accredited Standards Committee X12 (ASC X12) Version
005010 Technical Reports Type 3 for HIPAA Transactions
b. Proposed adoption of the National Council for Prescription Drug Programs
(NCPDP) Telecommunication Standard Implementation Guide Version D,
Release 0 (D.0) and Equivalent Batch Standard Batch Implementation Guide,
Version 1, Release 2 (1.2) for Retail Pharmacy Transactions
c. Proposed adoption of a standard for Medicaid Pharmacy Subrogation: NCPDP
Medicaid Subrogation Standard Implementation Guide, Version 3.0 for pharmacy
claims
d. Proposal to adopt NCPDP Telecommunication Standard D.0 and ASC X12
Version 005010 Technical Reports Type 3 for billing retail pharmacy supplies and
services
e. Proposed Modifications to Descriptions of Transactions
f. Proposed Compliance and Effective Dates

1
HIPAA MANDATED TRANSACTIONS

Per the final Rules Preamble: Level 1 – Acceptance Testing Period Begins (including Trading Partner Testing) and Level 2 –
Full Compliance (Transaction Version Implementation)

NUMBER NAME EXISTING VERSION NEW TRANSACTION/VERSION PROPOSED TIMELINES


270/271 Health Care Eligibility Benefit ASC X12N 270/271 ASC X12N/005010X279 Level 1 – 7/1/2010
Inquiry and Response 004010X092A1 Level 2 – 7/1/2011
276/277 Health Care Claim Status ASC X12N 276/277 ASC X12N/005010X212 and Level 1 – 7/1/2010
Request and Response 004010X093A1 Type 1 Errata Level 2 – 7/1/2011
278 Health Care Services Review – ASC X12N 278 ASC X12/005010X217 and Type Level 1 – 7/1/2010
Request for Review and 004010X094A1 1 Errata Level 2 – 7/1/2011
Response
820 Payroll Deducted and Other ASC X12N 820 ASC X12/005010X218 Level 1 – 7/1/2010
Group Premium Payment for 004010X61A1 Level 2 – 7/1/2011
Insurance Products
834 Benefit Enrollment and ASC X12N 834 ASC X12N/005010X220 Level 1 – 12/31/2010
Maintenance 004010X95A1 Level 2 – 9/30/2011
835 Health Care Claim Payment and ASC X12N 835 ASC X12N/005010X221 Level 1 – 12/31/2010
Advice 004010X91A1 Level 2 – 9/30/2011
837D Health Care Claim: Dental ASC X12N 837 ASC X12N/005010X224 and Level 1 – 12/31/2010
004010X97A1 Type 1 Errata Level 2 – 9/30/2011
837I Health Care Claim: Institutional ASC X12N 837 ASC X12N/005010X223 and Level 1 – 12/31/2010
004010X96A1 Type 1 Errata Level 2 – 9/30/2011
837P Health Care Claim: Professional ASC X12N 837 ASC X12N/005010X222 Level 1 – 12/31/2010
004010X98A1 Level 2 – 9/30/2011
NCPDP National Council for Prescription NCPDP Telecommunication NCPDP Telecommunication Level 1 – 12/31/2010
Drug Programs (NCPDP) Standard Implementation Standard Implementation Guide, Level 2 – 9/30/2011
Pharmacy Telecommunication Guide, Version 5, Release 1, Version D, Release 0, July 2007
Standards September 1999 and NCPDP Batch Standard Batch
NCPDP Batch Standard Implementation Guide, Version 1,
Batch Implementation Guide, Release 2, January, 2006
Version 1, Release 1,
January 1, 2000 (Open Issue on which format
option the agency will elect)

Last Updated: 08/20/2008


G:\HIPAA Library\Transactions+Code Sets\5010\5010 AHCCCS Website\Transactions Mods overview 3-4.doc
ACKNOWLEDGEMENTS
NUMBER NAME VERSION AHCCCS FILE REPLACED PROPOSED TIMELINES
TA1 Interchange Acknowledgement No Version; does not require Level 1 – 12/31/2010
a GS/GE Level 2 – 9/30/2011
997 Functional Acknowledgement Version number of the Version number of the transaction Level 1 – 12/31/2010
transaction being responding being responding to, i.e., if Level 2 – 9/30/2011
to, i.e., if compliant the compliant the version from the
version from the GS/GE from GS/GE from sender
sender (004010X97A1 or (004010X97A1 or 004010X96A1)
004010X96A1)
If an unknown or unexpected
If an unknown or unexpected version is received, a generic
version is received, a generic 004010 will be returned.
004010 will be returned.

NEW TRANSACTIONS

NUMBER NAME VERSION AHCCCS FILE REPLACED PROPOSED TIMELINES


NCPDP The NCPDP Medicaid The Batch Standard TBD as needed
Subrogation Transaction Medicaid Subrogation
Implementation Guide,
Version 3, Release 0, July
2007
999 Implementation ASC X12N/005010X231 997 for all health care mandated Level 1 – 12/31/2010
Acknowledgement for Health transactions. Level 2 – 9/30/2011
Care Insurance

** Concurrently evaluate the ability to generate necessary Subrogation 837 transactions (4010 to 5010), as needed.

Last Updated: 08/20/2008


G:\HIPAA Library\Transactions+Code Sets\5010\5010 AHCCCS Website\Transactions Mods overview 3-4.doc