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Implementation of the New Health Insurance Portability and Accountability Act Formats for all Durable Medical Equipment Medicare Administrative Contractor
Electronic Trading Partners
Front-end Reports The current X12 version 4010A1 electronic claims front-end reports created and produced by the Common Electronic Data Interchange (CEDI) (997, TRN and GenResponse) will be replaced with the 999 and 277CA transactions once an electronic trading partner begins using the new X12 version 5010 format. The 999 and 277CA transactions will not be readable without translation, so suppliers will have to get these new reports read by their software. The 999 and 277CA transactions are not HIPAA mandated; however, CMS is requiring these transactions for all Medicare business. Note: The TA1 produced by CEDI and the Certificate of Medical Necessity (CMN) rejection report produced by the durable medical equipment Medicare administrative contractors (DME MACs) and delivered by CEDI will continue to be produced for X12 version 5010 transactions. The current NCPDP version 5.1 front-end report created and produced by CEDI will be replaced with an NCPDP formatted transmission response report for NCPDP version D.0 claims. The version D.0 NCPDP transmission response report will not be readable with out translation, so suppliers will need to have these reports read by their software. PC-ACE Pro32 Users The PC-ACE Pro32 software will be updated for the new HIPAA X12 version 5010 claims format and made available in 2011. CEDI will provide notification via the CEDI Listserv and Web site as soon as the X12 version 5010 of the PC-ACE Pro32 software is available. Express Plus Users The Common Electronic Data Interchange no longer supports the Express Plus software; therefore it will not be updated for the new HIPAA X12 version 5010 format. All suppliers using Express Plus should have converted to PC-ACE Pro32 or another software program as of April 1, 2010. What You Need to Do All DME MAC electronic trading partners need to make sure their software programs will be ready for the new X12 version 5010 and/or NCPDP version D.0 standards according to the timelines listed above. National Government Services CEDI suggests you contact your software vendor, billing service or clearinghouse to make sure they are aware of the changes to the new HIPAA formats. A list of questions to ask your software vendor, billing service, or clearinghouse:
Additionally, The Administrative Simplification Compliance Act (ASCA) requires the use of electronic claims (except for certain rare exceptions) in order for suppliers to receive Medicare payment. Therefore, effective January 1, 2012, you must be ready to submit your claims electronically using the X12 version 5010 and/or NCPDP version D.0 standards. Remember, the X12 version 5010 and version D.0 HIPAA standards are national standards and apply to your electronic transactions with all payers, not just with fee-for-service (FFS) Medicare. Therefore, you must be prepared to implement these transactions with regard to your non-FFS Medicare business as well. Additional Information/Resources The Centers for Medicare & Medicaid Services has created an entire section of their Web site devoted to the new HIPAA formats, including a Medicare comparison of the current and new formats, at www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp. 
The Centers for Medicare & Medicaid Services Web site for industry-wide information, including upcoming free educational seminars is: www.cms.hhs.gov/Versions5010andD0/40_Educational_Resources.asp.
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