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5010 Resources
5010 Frequently Asked Questions
The following list of Frequently Asked Questions will assist Availity trading partners in their migration planning
General Background
Testing
Supported Transactions
Communication and Support
Related Information
General Background
What is essential to know about the conversion to HIPAA 5010 standards?
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 of 1996. These Final Rules are collectively known as “the 5010 Rules.”
The legislation mandates industry-wide migration from the current 4010A1 version to a newly established 5010 version, for health information transactions governed under HIPAA.
The legislation became effective on March 17, 2009. It established two levels of compliance to be attained over a one-year transition period that assures all HIPAA-covered entities achieve compliance by January 1, 2012.
Level 1 compliance, required by December 31, 2010
The HIPAA-covered entity can demonstrate that it can create and receive Version 5010 compliant transactions.
Level 2 compliance, required by January 1, 2012
The HIPAA-covered entity has completed end-to-end testing with all of its partners and is ready to move into full production with the new 5010 version.
Are my Availity transactions affected by the 5010 Rules?
The Rules will apply to the following electronic transactions processed by Availity:
| 270/271 | Eligibility Request and Response |
| 276/277 | Claim Status Inquiry and Response |
| 278 | Referral Certification and Authorization (request and response) |
| 835 | Healthcare Payment and Remittance Advice |
| 837D | Healthcare Claims – Dental |
| 837P | Healthcare Claims – Professional |
| 837I | Healthcare Claims – Institutional |
Who is affected by the transition to the new 5010 version of electronic transactions?
All HIPAA-covered entities transmitting health information in an electronic format are affected by the 5010 Rules. This group includes health care providers, health plans, clearinghouses, information trading partners and health information networks.
What do I need to do to make sure my records/ my organization adheres to the new 5010 standard?
Because you are an Availity customer, we are working to assure that any impact to your workflow will be minimal. Through Availity, information from your transactions/your customers’ transactions will be seamlessly routed and matched to accommodate the 5010 transaction handling capabilities of all parties with whom your information is exchanged.
Further, Availity offers assistance to trading partner companies to facilitate 5010 process migrations, and to certify testing for new processes against the Availity® Health Information Network.
Will Availity be able to handle 4010A1 transactions and 5010 transactions during the entire one-year transition period, or will there be a cut-off date when transactions have to be in the new format to be processed?
Since the 5010 Rules have such broad implications across the health care industry, it is understandable that organizations will be in varying stages of readiness during the next several months as they plan and implement new processes. Some Availity information trading partners (and some payers) are working toward a readiness date of January 1, 2011 to accept 5010 transactions, and some won’t be ready to accommodate 5010 transactions until later in the year.
For this reason, beginning January 1, 2011, Availity will automatically “up-convert” incoming 4010A1 transactions in order to deliver outbound 5010 transactions for exchange with those organizations ready to receive them, and conversely, will “down-convert” incoming 5010 transactions to the 4010A1 format, for exchange with partners who have not yet achieved readiness.
This assures that all Availity submitters/providers can submit transactions in the format preferred by their organizations, and all receivers/payers can receive transactions in the format preferred by their organizations.
The ability to do both “up-conversion” and “down-conversion” concurrently in real-time is an advantage to all our customers, and underscores Availity’s extensive flexibility in accommodating the needs of all information exchange partners.
Where can I learn more about the 5010 Rules, and the upcoming transition?
Return to this page for updates on Availity’s 5010 migration plan and support for Availity customers.
For more information about the 5010 Rules, the Centers for Medicare and Medicaid Services (CMS) have published a “Provider Action Checklist for a Smooth Transition” that you may find helpful in evaluating your 5010 readiness.
Will Availity convert ALL transactions to 5010 on a certain day?
Availity will be able to process 5010 transactions by the earliest date mandated in the Final Rules legislation, January 1, 2011. Beginning on that date, Availity can accommodate both 4010A1 and 5010 transactions, submitted and received. This allows Availity to accommodate the varying degrees of readiness among payers, providers, clearinghouses and other information partners.
We may not be ready to submit 5010 transactions on January 1, 2011. Can we still use Availity?
Since the 5010 Rules have such broad implications across the health care industry, it is understandable that organizations will be in varying stages of readiness during the next several months as they plan and implement new processes. Some Availity information trading partners (and some payers) are working toward a readiness date of January 1, 2011 to accept 5010 transactions, and some won’t be ready to accommodate 5010 transactions until later in the year.
For this reason, beginning January 1, 2011, Availity will automatically “up-convert” incoming 4010A1 transactions in order to deliver outbound 5010 transactions for exchange with those organizations ready to receive them, and conversely, will “down-convert” incoming 5010 transactions to the 4010A1 format, for exchange with partners who have not yet achieved readiness.
This assures that all Availity Submitters/Providers can submit transactions in the format preferred by their organizations, and all Receivers/Payers can receive transactions in the format preferred by their organizations.
The ability to do both “up-conversion” and “down-conversion” concurrently in real-time is an advantage to all our customers, and underscores Availity’s extensive flexibility in accommodating the needs of all information exchange partners.
How will Availity determine which record format should supersede/dominate/drive the transaction, during the period of time from January 1, 2011 to January 1, 2012?
Payer readiness will determine the format/version, as well as the effective date, for each transaction.
During the one-year transitional period, Availity will accept either incoming record format (4010A1 or 5010) from a submitter, and will “up-convert” or “down-convert” it to the payer’s preferred format so the transaction can be completed.
For paired transactions (270/271 Eligibility and Benefits Inquiry and Response, 276/277 Claim Status Inquiry and Response, etc.), the response returned to the submitter will be in the same version as the initial inbound inquiry transaction. Availity will make any necessary up- or down-conversions to display the information in the customer’s preferred format.
What happens when Availity “up-converts” or “down-converts” a file from 4010A1 to 5010 or vice versa?
Availity has selected a world-class information partner, Informatica, to provide maximum flexibility to submitters, trading partners and payers during the transition to 5010 Rules. Availity selected Informatica because their tools will enable seamless mapping of information from any format, to any format, so Availity can accommodate the preferred style of all information exchange partners.
When Availity “up-converts” a file, it conveys data from a submitted 4010A1-formatted transaction to the corresponding necessary data fields on the 5010 record format. This means that the 4010A1 transaction is now converted “up” to the minimum standard necessary to comply with 5010 transaction requirements.
Conversely, if a submitter sends a 5010 formatted record to a payer not yet equipped to handle 5010 files, Availity will “down-convert” the 5010 record by mapping data from it to the corresponding necessary data fields in the older 4010A1 format.
Either or both scenarios may be used to complete a round-trip information exchange between a submitter and payer. In any event, it is Availity’s goal to present the information to the end-customer in whichever version they prefer and can process.
Will Availity send 835s in the same format (5010 or 4010A1) as the 837 claim?
Trading partners can designate their preferred 835 remittance version in their user preference settings. This allows trading partners the flexibility and time to test their posting and processing of remittance transactions, independent of the claim transaction, to ensure cash flow is not negatively affected.
Will Availity accept both the 4010A1 and 5010 versions simultaneously, and for how long?
Availity will accept either the 4010A1 or 5010 versions from submitters. There are no plans at this time to eliminate the 4010A1. Availity will continue to accept the 4010A1 version after the January 1, 2012 compliance date.
When will Availity stop accepting (or offering) 4010A1 version transactions?
Availity currently has no plans to discontinue support for 4010A1 transactions.
Testing
Testing Milestones
When will Availity begin testing 5010 transactions?
In anticipation of our customers’ needs, Availity has already begun Level 1 Internal testing to meet the January 1, 2011 date, per the Final Rules legislation.
Will Availity test 5010 versions with all receivers/payers?
Yes, in Level 2 testing, Availity will establish a testing process for receivers/payers that choose to test with Availity.
Receivers/Payers who complete testing with Availity earn the privilege to display the Availity 5010 CertifiedSM logo in their environments, to promote their market leadership and process readiness to customers. More information about the Availity 5010 CertifiedSM program will be published as it becomes available.
Will Availity test the 5010 versions with all providers/submitters?
Availity works closely with practice management system vendors to verify their products. Once a vendor’s 5010 product has been verified, individual user testing is encouraged, but not mandatory. Additionally, since Availity will continue to support 4010A1 transaction versions, not all users will choose to migrate to the 5010 version.
Providers/Submitters who voluntarily complete testing with Availity earn the privilege to display the Availity 5010 CertifiedSM logo in their software or on their Web sites, to promote their market leadership and process readiness to customers. More information about the Availity 5010 CertifiedSM program will be published as it becomes available.
When will Availity be ready to test submission of files in the 5010 version?
Availity will be ready to test real-time transactions from business-to-business submitters (not portal submitters) beginning January 2011.
Availity will be able to test transactions with batch EDI submitters beginning January 2011.
Web portal users will not be required to test their connections; Availity will test with individual payers as they are implemented throughout 2011, with the goal of having all portal transactions migrated by the federally-mandated deadline of January 2012.
Please see the timeline chart above.
Will Availity have a dedicated testing environment for 5010 testing?
Yes, Availity will have a dedicated 5010 testing environment available for trading partners.
Will Availity require enrollment for 5010 testing and production?
New enrollment will not be necessary; however, activation in the designated 5010 testing environment is required. Availity implementation staff will work with you to complete activation after the testing kick-off call. Once testing is completed and production approval is granted, users may immediately begin submission of 5010 transactions in production.
Will trading partners have to obtain new IDs to test 5010 transactions?
No, trading partners can use their existing account information for 5010 testing.
Will 5010 transactions be tested and implemented all at once, or staggered by transaction type?
Availity is staggering the internal testing and implementation of 5010 transactions; however, all transactions covered by the Final Rules will be available for EDI batch and B2B testing by external users by January 1, 2011. Portal / Web-entered transactions will be migrated to 5010 versions based on payer readiness by transaction.
How do payers and PMS vendors engage Availity for 5010 testing?
Availity will be reaching out to payers and vendors beginning in June, 2010, to begin the implementation process. Payers and vendors may contact their Alliance/Account Managers to schedule their testing and implementation any time after June if they have not received a call from Availity.
When will Availity portal users see a new interface that prompts them to populate a 5010 record format?
Availity will update portal screens with the new 5010 data input fields as the individual payers indicate their readiness to accept 5010 transactions.
All Availity portal screens will be updated to the 5010 version no later than January 1, 2012, since all payers, by law, will be fully implemented by that date.
Supported Transactions
Available in 4010A1 and 5010
| 270/271 | Eligibility Request and Response |
| 276/277 | Claim Status Inquiry and Response |
| 278 | Referral Certification and Authorization (request and response) |
| 835 | Healthcare Payment and Remittance Advice |
| 837D | Healthcare Claims – Dental |
| 837P | Healthcare Claims – Professional |
| 837I | Healthcare Claims – Institutional |
Available in 5010 only
| 999 | Implementation Acknowledgment for Health Care Insurance (ASC X12C/005010X231) |
| 277 | Health Care Claim Acknowledgment (ASC X12/005010X214) |
Will Availity support the new 999 Implementation Acknowledgment for Health Care Insurance (ASC X12C/005010X231) and/or the 277 Health Care Claim Acknowledgment (ASC X12/005010X214) transactions?
Yes, Availity will support both of these new transaction sets in response to a 5010 version (only) even though HIPAA is not mandating their use at this time. The 999 will be available in an X12 and a human readable text format.
Availity and other industry leaders believe that acknowledgments are important to the industry and standardization of these transactions will move the industry closer to achieving the administrative cost savings envisioned by the HIPAA legislation. Trading partners will be able to select these transactions beginning with our 5010 implementation.
Will Availity continue to offer delimited and text response file formats?
Yes, Availity will continue to offer the current delimited and text response file formats for 5010 claim submissions. We will make enhancements to the Availity response formats in conjunction with our 5010 implementation. We will communicate changes to you in a timely manner so you can make the appropriate changes to your systems and processes.
Will Availity support the 824 - Application Reporting for Insurance (ASC X12N/005010X186) transaction?
No, Availity has no plans to support this transaction at this time.
Will the same submission methods (i.e. FTP, File Upload, etc.) be supported for both 4010A1 and 5010 files?
Yes, Availity will continue to support all of the current communication/transmission modes. There will be minor changes to the business-to-business (B2B) XML messages as a result of 5010. These changes will be communicated to B2B trading partners during their 5010 implementation.
Will you use a 5010 validation tool to validate data as part of the 5010 implementation? If so, what tool will you be using?
Yes, Availity will continue to use our existing EDIFECS validation tool to perform 5010 HIPAA compliance validation.
Will Availity impose any fees for 5010 transactions?
Availity has no current plans to impose fees to submitters of 5010 transactions.
Communication and Support
How does Availity prefer to communicate with users regarding 5010?
Availity encourages trading partners to monitor this Web site for updates regarding our 5010 implementation. We will publish all timelines and instructions here.
How do I contact Availity with questions about 5010?
We have established a special e-mail account that can be used to submit additional questions to our 5010 project team members: 5010@availity.com. Please allow several business days for a response.
Will Availity be offering training or information sessions on the transition to 5010?
Yes, Availity will incorporate the subject into existing demos, Webinars and release training currently offered. Please check our Training web site for details and new courses as they are promoted.
Will Availity supply a companion guide by transaction type? If so when?
Availity supports the ACS X12 5010 TR3 (Implementation Guide) for all transactions and all payers. Information specific to individual payers will be documented in their respective companion guides. The Availity EDI Guide documents any Availity-specific enveloping requirements and payer-specific edits.
Related Information
Has Availity begun work on the ICD-10 implementation?
Yes, Availity has begun ICD-10 implementation planning in line with the federally mandated timeframes. We will share our plans externally when they are formalized. Please check back with your Availity Alliance Manager, Account Manager or monitor this area of our Web site for future updates.