White Paper

I T a n d B P O S o l u t io n s

Are you Ready for

ICD-10 and HIPAA 5010
Impacts and Preparedness of Payers
HIPAA 5010 Summary
Health Insurance Portability and Accountability Act (HIPAA) plays a vital role in safe guarding
patient’s privacy and protecting the health information. Its main intention is to economize billions
of dollars by altering the complex process of claims administration and payments through a single
standard for healthcare transactions. HIPAA 5010 is going to bring a significant growth in improving
the efficiency and reducing the maintenance costs to large extent for organizations planning to
meet federal government regulations and deadlines quickly. But the biggest challenge in front for
companies is understanding the complexity of the new emerged healthcare standards.

It should be viewed as an opportunity to combine all these standards with steps to integrations
all the business process to better communicate with trading partners and stay competitive.

If you are ready to meet the competition and win the healthcare market in coming future, you
should act promptly in choosing a flexible and advanced technology. Besides a choosing a partner
who is consistent and committed in providing a cost effective solution by meeting deadlines is
also important.This is where HIPAAVillage LLC assures you all kind of capabilities and qualities in
implementing the HIPAA compliance
HIPAA X12 4010 to 5010

What is the 4010 to 5010 conversion and what does it involve?

Version 4010 was adopted on August 17, 2000 and included standardization of 9 formats for electronic data
transmissions (paper transactions are excluded at present).They included:

PLAN
PROVIDER HEALTH PLAN
EMPLOYER
GROUP

Patient Scheduling Eligibility Inquiry 270

Pre-Registration Enrollment Subscriber
Contract Enrollment 834 (Member)
Registration
Admission Plan Management Enrollment
Elig. Response 271

Premiums
Accounts Accounts Payable
Premium Pay 820
Receivable Premium Payment

Auth Request 278

Patient Care Case Pre-Adjudication
Management Utilization Review
Utilization Review
Auth Response 278

Claim/COB 837
Claims Processing
Need More Info 277 Adjudication
Billing Payer to Payer COB837
Or
Encounters
Attachment 275

Status Inquiry 276

Collections
Status Response 277 Claims Payment
Accounts
Accounts Payable
Receivables
Remitt. Advice 835

The 5010 Version is massive and includes more than 850 complex changes. For example, the changes to the
Healthcare claim, transaction 837, include 700 pages of instructions with a change on every page. This HIPAA
format conversion must be completed by January 1, 2012, in advance of the ICD-10 implementation in order
to accommodate the extended diagnosis/procedure codes.

It is also critical that during the 5010 conversion, payers and providers operate dual processing systems - one
to process live claims with 4010 formats and a second to process 5010 transactions for testing and analytics.
Approach to HIPAA 5010 compliance

Ÿ Change analysis will require a thorough review of all transactions

Ÿ Each payer should review their 4010 A1 implementation against 5010 guidelines, with
particular attention to situational rules
Ÿ Changes are not 100% with some transactions changing very little, some moderately, and
others, such as claims transactions, changing dramatically
Ÿ New interfaces must be identified and built
Ÿ Data elements must be assembled to match the 5010 layout and tested thoroughly
Ÿ Implemented in compliance with the mandated completion date of January 1, 2012

How are ICD-10-CM and ICD-10-PCS different from ICD-9-CM?

When the original ICD code sets were adopted by theWorld Health Organization, they did not include
procedure codes for facility providers. The ICD-9 code sets included 13,000 diagnosis codes and no procedure
codes. At that time, the US healthcare industry added 11,000 facility procedure codes and designated the
combined codes set as ICD-9-CM.

The new code sets are now in two segments.ICD-10-CM increases diagnosis codes from 13,000 to 68,000
codes. The accompanying ICD-10-PCS code set includes facility procedure codes and increases the total
content from 11,000 to 87,000 codes.The mandated implementation date for both code sets is October 1,
2013.

Together, these two expanded code sets will enable far more effective data for the vital classification of
morbidity and mortality data while enabling accurate claims management and reimbursement by the insurance
industry.They will advance effective disease management programs and track outcomes of care to ensure
quality.

To effectively undertake the massive projects, these two interdependent conversions require, and to complete
implementation within the time frames mandated by the Federal Government, there are key strategic steps we
recommend be followed.To follow are 10 Critical Success Factors we have identified to ensure understanding
of the changes themselves, the areas within the payer that will be affected and the steps to be completed to
meet these very complex, resource dependent and unfunded mandates.
HIPAA Village - Implementation Strategy
A phased approach to accomplish successful implementation of these complex changes:

Discovery Impact Analysis Remediation QA and

Phase Phase Phase Testing
Phase

Discovery phase An up-front analysis to identify processes impacted and catalog issues related to benefit
changes, provider contracts, state regulatory mandates, medical case management policy changes, staffing
issues, testing, and vendor management.

Analysis phase Each affected system, process, or staff grouping would undergo an in-depth analysis to
determine the extent of impact. The exit criterion is a detailed matrix identifying the magnitude of impact in
each area.

Remediation phase The Discovery and Analysis phases will result in a detailed roadmap to enable
compliance to 5010 and ICD-10 criteria. This includes re-engineered solutions, validation, implementation, and
testing for go-live production.
HIPAAVillage Product Services Offerings

Payor administration solutions -

Ø Erisco Facets - Consultants with strong Facets and hands on configuration experience.

Ø Functional areas: enrollment, provider reimbursement, provider set up, member service, provider service, claims

processing, benefits set up, billing or accounts receivable

HIPAA-EDI & e-commerce productivity tools

We can build the foundation of your e-commerce enterprise using EDISIM suite

Ø Instream: Transaction validation engine, to ensure compliance of inbound and outbound HIPAA EDI data, Standards Editor

* Standards Reference * Doc Builder * Analyzer Components * Comparator * Test Data Generator Using networks.

Ø We the Edifecs solution suite - CommerceDesk and SpecBuilder - reduce costs and time-to-market for companies

building trading networks or participating in trading exchanges. Edifecs, we can accelerate the deployment, ramp-up,

and management of large-scale B2B trading

Translation Services

Ø Our certified WebSphere Message Broker Developers will help you to implement a broker-based application that distributes

and transforms real-time information and establishes end-to-end communications using IBM WebSphere Message Broker

V6.1

Ø We support our customers' WTX / EDI initiatives through a range of service offerings that include consulting, custom

WTX development, Mercator to WTX migration and WTX application support and maintenance.

Ø Services in the following different products of Sterling commerce to best accommodate your e-business needs on

different operating systems like Mainframes, Windows, Unix.

· Gentran:Basic

· Gentran:Director

· Gentran:Server

· Managing file transfer with Connect: Enterprise and Connect:Direct

 I T a n d B P O S o l u t io n s

HIPAAVillage Transition Services Offerings

Impact Assessment Remediation QA & Testing

Assessing and analyzing existing Solution design Test consulting

coding and reimbursement
systems, data sources and Business rule configuration Functional testing
decision-support systems
Mapping System testing
Evaluating Interfaces between
code entry department and Integrations Regression testing
electronic billing using the
UB-04/HCFA 1500 format Trading partner agreement User acceptance testing
configuration
Reviewing financial information Performance testing
connected with reimbursement Coding
Volume testing
Review clinical, PACS, EMR et.al. Deployment & Go-Live
systems Stress testing
Support & Maintenance
Test automation

Why HIPAA Village?

Ø Assurance of reducing costs by at least 45%

Ø Over 200 resources who have extensive experience in Gentran, GIS, TLE, TIE tools and technologies

Ø One stop shop for B2B services

Ø Expertise in Integration with internal applications and databases

HIPAA Village LLC.

56 THOMPSON ST, ALPHARETTA, GA 30009
www.gallegasoft.com - kevin@hipaavillage.com
Sales: (678) 388 9652