HHS Issues Final Rules on HIPAA v5010/NCPDP D.0 and ICD-10 Implementation; White House Action Puts Timeline in Question
Early in January 2009, the Department of Health and Human Services (HHS) finalized two important sets of rules regarding EDI transactions. The rules, set to go into effect in March 2009, could be subject to change after the White House issued a memorandum stating it will further review any regulations that have been published but have not yet gone into effect.
HIPAA v5010/NCPDP D.0
On January 16, 2009, HHS issued its Final Rule on modifications to administrative simplification regulations under the Health Insurance Portability and Accountability Act (HIPAA). These rules update the HIPAA electronic transaction standards to the X12 standard, Version 5010 and the National Council for Prescription Drug Programs (NCPDP) standard Version D.0. The Final Rule changed the compliance date from April 2010 (in the proposed rule) to January 1, 2012.
The Final Rule introduces a compliance timeline for HIPAA v.5010/NCPDP D.0. Under the new HHS compliance timeline:
• Covered entities should have designed, developed and tested their own systems prior to January 1, 2011.*
• Trading partners should have tested the interchange of transactions and implemented connections using the revised standards by January 1, 2012. *
* These dates could be subject to change pending review of the Final Rules by the White House.
ICD-10 Implementation
HHS also issued final rules for implementing a revised version of the International Classification of Diseases Clinical Modifications and Procedure Coding System (ICD-10 CM and ICD-10 PCS) as a HIPAA standard code set. The agency received numerous comments expressing concern about the move to ICD-10, but it determined that the transition was necessary to address challenges with Medicare. The compliance deadline for ICD-10 is October 1, 2013. *
* This date is also subject to change pending White House review.
Emdeon Readies for the Transition; Gap Analysis Guides the Effort
HHS issued proposed rules in August of 2008 and received extensive input from industry organizations and individual payers, providers, vendors and others. Emdeon worked with several key industry and standards organizations to prepare comments and also submitted its own comments on behalf of its customers and business partners.
Since then, Emdeon mobilized an experienced team of subject matter experts to analyze the potential impact of the regulations and to develop a comprehensive approach to the transition.
The first step was to conduct a data gap analysis for all of the HIPAA transactions that Emdeon supports. Project teams were formed for each transaction type for Version 5010 and NCPDP Version D.0. Specific transactions include the following:
X12: 5010
• 837 Health Care Claim: Professional
• 837 Health Care Claim: Institutional
• 837 Health Care Claim: Dental
• 835 Health Care Claim: Payment/Advice
• 270/ 271 Eligibility/Benefit Inquiry and Information Response
• 276/ 277 Health Care Claim Status Request and Response
• 278 Health Care Services Review– Request for Review and Response (Referral Certification and Authorization)
NCPDP: Pharmacy
• D.0 Claims & Encounters
• D.0 Eligibility
• D.0 Referral Certification & Authorization
• D.0 Coordination of Benefits
Emdeon’s internal gap analysis between 4010A1 and 5010 for the X12 transactions and between V5.1 and D.0 for the NCPDP has been completed and is unchanged by the Final Rules. Once the gap analysis and business requirement documentation are complete, Emdeon will share HIPAA Guidance reports with its customers, just as it did for 4010A1 and the NPI, and provide shared roadmaps for implementation.
Commitment and Customer Support
Emdeon’s 5010 Transaction Teams and 5010 Steering Committee are finalizing action plans and deploying resources to address the changes required in the new regulations. Emdeon will work with early implementers to help ensure their needs are met.
Emdeon remains committed to meeting and exceeding the compliance deadlines and supporting its customers and business partners in their implementation efforts through progress updates, educational resources, simplified reporting and consulting services. The company’s overall goal is to be ready to test well in advance of HHS deadlines.
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