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					         SOUTH DAKOTA 5010 and NCPDP GENERAL INFORMATION

What is 5010 and D.O?

HIPAA X12 version 5010 and NCPDP Version D.O are new standards that regulate
the electronic transmission of specific healthcare transactions, including eligibility,
claim status, referrals, claims and remittances. Covered entities, such as health
plans, healthcare clearinghouses, and healthcare providers, are required to conform
to HIPAA 5010 standards.

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

Use of the 5010 version of the X12 standards and the NCPDP D.O standards is
required by federal law. The compliance date for use of these standards is January
1, 2012.

Who will need to upgrade to HIPAA 5010?

All covered entities, listed below, that submit electronic transactions through the
FTP or Launch Pad to SOUTH DAKOTA Medical Assistance are required to
upgrade to HIPAA 5010 standards, covered entities may use a clearinghouse/billing
agent to assist them with complying with the rules.
    • SD Medical Assistance Providers
    • Payers
    • Clearinghouses
Additionally, even though software vendors are not included in the list of covered
entities, in order to support their customers they will need to upgrade their products
to support HIPAA 5010. Systems that submit claims, receive remittances, and
exchange claim or eligibility status or eligibility inquiry and responses must be
analyzed to identify software and business process changes.

Please note: Dental services billed electronically as an 837D, which is equivalent to the
ADA paper claim form, need to be submitted directly to Delta Dental and not SOUTH
DAKOTA Medical Assistance.

If you submit claims for dental-related services such as oral surgery that are billed on
an 837I or 837 P (paper equivalent is UB04 or CMS 1500), you are submitting claims
directly to SOUTH DAKOTA Medical Assistance.

Who will need to upgrade to NCPDP D.O Standards and how will it affect individual
pharmacies?
Your software vendor will have the most comprehensive answer to this question. It
is important that you verify they have a plan in place to update your system and
conduct testing. You will most likely continue to submit electronic pharmacy claims
through direct switches that have been established with Web MD, QS/1 Data
Systems, and National Data Corporation. South Dakota Medicaid plans to test
directly with the established switches prior to implementation.

If you are a pharmacy and are receiving a HIPAA 5010 835-- Health Care Claim
Payment/Advice (Remittance Advice) through a Trading Partner Agreement with
SD Medical Assistance, we encourage you to sign up for the 5010 Listserv at
http://listserv.state.sd.us/scripts/wa.exe?A0=EDITRANSACTION to receive continued 5010
updates.



What transactions are specified in the HIPAA 5010 and NCPDP D.O standards?

   •   2701/271 - Health Care Eligibility Benefit Inquiry and Response
   •   276/277 - Health Care Claim Status Request and Response
   •   278 - Health Care Services - Request for Review and Response; Health Care
       Services Notification and Acknowledgement
   •   820 - Payroll Deducted and Other Group Premium Payment for Insurance
       Products
   •   834 - Benefit Enrollment and Maintenance
   •   835 - Health Care Claim Payment/Advice (Remittance Advice)
   •   837 - Health Care Claim (Professional, Institutional, and Dental) including
       coordination of benefits (COB) and subrogation claims
   •   NCPDP D.0—Pharmacy Claim

What are the major differences in the HIPAA 5010 and NCPDP D.O standards?

Version 5010 differences include:
   • Standardization of business information related to the transaction;
   • Definitions of what specific dates need to be collected and transmitted;
   • Accommodation for the reporting of clinical data, such as ICD-10 CM
      diagnosis codes and ICD-10 procedure codes;
   • The ability to distinguish between principal diagnosis, admitting diagnosis,
      external cause of injury, and patient reason for visit codes;
   • Information to support the monitoring of certain illnesses, mortality rates,
      outcomes for specific treatment options, some hospital length of stays and
      clinical reasons for care; and
   •  Information to meet unmet business needs, such as an indicator on
      institutional claims for conditions that were “present on admission.”
Version D.O differences include:
   • New data elements and rejection codes to facilitate Medicare Part D and
      coordination of benefits claim processing:
   • Complete eligibility information for Medicare Part D and other insurance
      coverage;
   • Information that identifies patient responsibility, benefit stages and coverage
      gaps on secondary claims better; and
   • The facilitation of the billing of multiple ingredients in processing claims for
      compounded drugs.

What is the timeline for implementation of HIPAA 5010 and NCPDP D.O standards?

South Dakota Medical Assistance has received approval from CMS to implement
5010 Transactions in three phases. The following are transactions associated to
each phase:

Phase One: Implementation complete by December 31, 2011
   • 2701/271 - Health Care Eligibility Benefit Inquiry and Response (Real-Time)
   • 835 - Health Care Claim Payment/Advice (Remittance Advice)
   • 837 - Health Care Claim (Professional, Institutional, and Dental) including
       coordination of benefits (COB) and subrogation claims
   • NCPDP D.0 - Pharmacy Claim
Phase Two: Implementation complete by January 31, 2012
   • 277U - Health Care Claim Status Response Unsolicited
   • 834 - Benefit Enrollment and Maintenance
Phase Three: Implementation complete by March 31, 2012 (Note: At this time,
South Dakota does not have any Trading Partners that are utilizing these
transactions.)
   • 276/277 Batch - Health Care Claim Status Request and Response
   • 278 - Health Care Services - Request for Review and Response; Health Care
       Services Notification and Acknowledgement
   • 820 - Payroll Deducted and Other Group Premium Payment for Insurance
       Products
   • 2701/271 Batch - Health Care Eligibility Benefit Inquiry and Response

Why is it necessary to upgrade to HIPAA 5010 and NCPDP D.O standards?

The upgrade to HIPAA 5010 and NCPDP D.O. is necessary to address
unanticipated issues and requirements that are not addressed with current
standards and to accommodate the forthcoming mandatory ICD-10 CM and ICD-10
PCS code sets, which are required to be implemented by the federal government on
October 1, 2013.

What happens if I don’t switch to Version 5010 and NCPDP D.O?

Electronic transactions submitted on or after January 1, 2012 will reject and not be
processed.

Will South Dakota Medical Services except HIPAA 4010 and NCPDP 5.1 standard
transactions after January 1, 2012?

Use of the 5010 version of the X12 standards and the NCPDP D.O standards are
required by federal law. South Dakota Medical Services will not be able to accept
4010 and 5.1 transactions.

We do not currently submit electronic claims but would like to. Is there a way that we
can do those?

Yes, you may establish a Trading Partner association with South Dakota Medical
Assistance. You may do this by contacting our office at 605-773-3495 or completing
the “Contact Us” form at http://dss.sd.gov/sdmedx/contact_us.aspx and selecting
Electronic Claims Submission as a topic and someone will contact you.

Where is the companion guide for South Dakota Medical Assistance HIPAA 5010 and
NCPDP D.O standards?

South Dakota does have companion guides available for HIPAA 5010 and NCPDP
D.O standards. The companion guides have been made available for each specific
HIPAA transaction and NCPDP D.O. As additional transactions are completed
they will be posted at this location:
http://dss.sd.gov/sdmedx/includes/providers/hipaainfo/index.aspx


Will a new Trading Partner Agreement need to be filed for the 5010 implementation?

No, the provider, billing agent or clearinghouse will not have to complete a new
Trading Partner Agreement due to 5010 implementation. If there is no Trading
Partner Agreement on file for the Legacy MMIS system, a Trading Partner
Agreement will need to be filed.

Who do I contact with general questions about 5010?

Please address your 5010 general information questions to the Provider Response
Team at 1-866-718-0084 or email SDMEDXEDI@state.sd.us. Over the next several
weeks, listserv updates on what is available for the 5010 and NPCDP D.O
implementation including details on testing will be sent. Please sign up for this
listserv at http://listserv.state.sd.us/scripts/wa.exe?A0=EDITRANSACTION.

Is there a website for 5010 information? If so what is the link?

HIPAA 5010 and NCPDP D.O information is being posted on the HIPAA
Information portion of the SD MEDX website at
https://dss.sd.gov/sdmedx/includes/providers/hipaainfo/index.aspx

When will South Dakota Medical Assistance begin testing?

South Dakota plans to begin testing transactions as they are finalized. Testing will
begin in October, 2011. For the most recent testing information, please visit the
HIPAA Information section of the SD MEDX website at
https://dss.sd.gov/sdmedx/includes/providers/hipaainfo/index.aspx. We also
encourage you to sign up for the 5010 Listserv at
http://listserv.state.sd.us/scripts/wa.exe?A0=EDITRANSACTION.


 

				
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