The full nine digit zip code must be included on all claim address information (e.g., Billing, Pay to, Mailing, Service location, etc). Please do not use a default to “zip+0000”, you must use complete and accurate ZIP code information.

Have you heard or read the Centers for Medicaid & Medicare Services (CMS) news release regarding a 90-Day Period of Enforcement Discretion for Compliance with New HIPAA Transaction Standards? Below is a clarification of what this means to you.

The deadline for the v5010 compliance did not change. The date for compliance was January 1, 2012. Please continue moving forward with your v5010 testing and production implementation.

The “Delayed Enforcement” means that CMS will not be proactively auditing covered entities for transaction compliance until after March 31, 2012. It is important to understand that from March forward, CMS will be conducting random audits on a sampling of covered entities. This is another reason to have everything completed by the end of the year so you can fine-tune any issues you find once you go to production.

Providers and payers (covered entities) can still file complaints during this “Delayed Enforcement” time period against those trading partners that are non-compliant. This would result in a CMS investigation of the complaint and, if the parties are found to be grossly negligent or without a contingency plan, there could still be penalties levied. If you know you are going to be late with transactions, you need to have your written contingency plan in place.

We all need to keep moving forward with the v4010 to v5010 transition. The delayed enforcement will allow the health care industry to resolve any last minute problems that are identified in the transactions as we begin sending production transactions on January 1, 2012. We can then be prepared for any audits after March 31, 2012.

• View the complete CMS article.

Effective January 1, 2012, taxonomy codes are required for HIPAA v5010 837 P, I and D claims..

The Health Care Provider Taxonomy Code Set is 10-digits and alpha numeric (e.g., 208D00000X). It is designed to classify health care providers by type and specialty.

• Providers may have more than one taxonomy code. (A complete list of taxonomy codes can be obtained from the Washington Publishing Company website.)
• The taxonomy code is intended to allow a health plan to be able to identify a provider's specialty and is used to correctly identify a provider and/or price a claim appropriately.
• During the National Provider Identifier (NPI) enrollment process, providers must select a primary and, if applicable, a secondary taxonomy code associated with their provider type. Providers are supplied a list of taxonomy codes to choose from that correspond to the type of services the provider renders.

Helpful taxonomy code submission information:

• Report taxonomy code in the PRV segment.
• If a taxonomy code is present, it must be valid.
• If you send a rendering provider loop, include the PRV at the 2310B level. If no rendering provider loop, include the PRV at the 2000A level.
• Note: You cannot send a taxonomy code in both the billing and rendering level on the claim.

A taxonomy code will also be required when submitting paper claims beginning January 1. If no taxonomy code is present, it could delay the processing of your claim or result in an incorrect payment.

• Review ADA J400, UB-04 and CMS-1500 field taxonomy code requirements.

To better support v5010 we have changed our NPI rules. Please submit your NPI only on your claims. We will no longer accept legacy provider numbers on the following electronic claim transactions:

837 - Health Care Claims:

• D - Dental
• I - Institutional
• P - Professional

This rule applies to all claim transactions. You can make these changes in advance of v5010 implementation while sending v4010A1. Note: Your Tax Identification Number (TIN) must be reported in loop segment 2010BB. Please do not report your legacy provider number in this loop.

Claims processing and payment may be delayed if your NPI is not included on your claim. If you do not have an NPI please enumerate as soon as possible to ensure timely and accurate processing of your claims.

• View additional NPI information

The following information regarding v5010 changes to address requirements may be helpful.

The v5010 format has three different address fields that providers need to complete:

• Billing address (the location where the service was rendered)
• Mailing address
• Pay-to address

Billing Provider Address

The billing provider address is the street address where the services were provided, which may or may not be the mailing address. The purpose of this information is to ensure that providers receive remittance advices at the correct payment location.

The Billing Provider Address is reported in the 2010 AA, N3 of the 837 claim transaction and must contain only a street address, also known as a physical address.

If your office is in a rural location, you can no longer report a P.O. Box in the Billing Provider loop. You must report your street address. If you do not know the street address, contact your local Post Office to obtain the address or the best description of your physical location.

Note: P.O. Box and lock box addresses cannot be reported in the N3 Billing Provider Address segment. If you use a P.O. Box address in this segment, your 837 will be considered out of compliance and your claim will not be accepted.

Payment delivery location

If you use a P.O. Box or lock box address as the delivery location for payments, continue to report the P.O. Box address in the Pay-to Address segment as previously.

2010-AA Billing Address and 2010 AB Pay-to-Address

Use only 2010 AB Pay-to-Address if you receive payment at a P.O. Box. Note: If you do not include any information in the Pay-to-Address segment, this indicates to Regence that you would like your remittance sent to the billing provider/physical location street address.

If you did not use your street address when you enrolled with Regence, it might cause a problem. We use the address that you provided at initial enrollment. You do not need to submit any changes if you want to receive payment exactly as you do today and you will be using the following v5010 provider loops correctly:

• 2010 AA Billing Address - can only contain street addresses
• 2010 AB Pay-to Address - use only if you receive payment at a P.O. Box. If you change your billing address to a street address from a P.O. Box and do not include the Pay-to Address information, we may not be able to identify you, causing claims to be pended or rejected. Note: If you do not include any information in the Pay-to-Address segment, this indicates to Regence that you would like your remittance sent to the billing provider/physical location street address.

Please monitor your 277CA and 999 reports and fix any errors that are listed.

On January 16, 2009, the U.S Secretary of Health and Human Services issued Final Rules for updated versions to the electronic transactions originally outlined under the Administrative Simplification Subtitle of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA 5010 is comprised of these rules.

The legislation mandates industry-wide migration from HIPAA 4010A1 to HIPAA 5010 for electronic health information transactions effective January 1, 2012.

HIPAA X12 version 5010 and National Council for Prescription Drug Programs (NCPDP) version D.0 are the new sets of standards that regulate the electronic transmission of specific health care transactions, including:

• Claims
• Eligibility
• Referrals
• Remittances
• Claim status

The following covered entities are required to conform to HIPAA 5010 standards:

• Hospitals
• Pharmacies
• Health plans
• Health care clearinghouses
• Dentists and other dental professionals
• Physicians and other health care professionals

The current transaction standard is X12 version 4010A1 for eligibility, claims status, referrals, claims, and remittances; and NCPDP version 5.1 for pharmacy claims.

2009

• January 16
  • Final rule published
• March 17
  • Rule in effect
    

2011

• January
  • 4010A1 continues in dual-use
  • Begin testing with your clearinghouse partner

2012

• January 1
  • Full compliance for 5010
• March 31
• CMS “Delayed Enforcement” period ends