CMS announces delay in enforcement of new standards for electronic claims submission

Psychologists will want to check to make sure that the payor or clearinghouse has upgraded to the 5010 format

By Legal and Regulatory Affairs staff

December 8, 2011—This article provides a brief update in light of recent questions from psychologists about new standards for the technical format of electronic claims known as HIPAA Version 5010.

January 1, 2012 is the effective date for the 5010 standards, which apply to all entities covered by the Health Insurance Portability and Accountability Act (HIPAA). Entities affected by the transition to HIPAA 5010 include providers, health plans, health care clearinghouses and business associates (such as billing/service agents and vendors). However, the Centers for Medicare and Medicaid Services (CMS) recently indicated that it will delay enforcement action related to this requirement for any HIPPA-covered entity for an additional three months.

While these changes take effect in January, most psychologists will have little if anything to do since the electronic formatting changes generally are handled by third-party payors and clearinghouses.  Psychologists will want to check to make sure that the payor or clearinghouse has upgraded to the 5010 format. If you are using electronic health record or practice management software, check with your vendor to determine if any upgrades/downloads are necessary to ensure that your electronic systems will work with the new format.

This HIPAA 5010 update was developed to address some issues in the previous 4010A system and to accommodate the forthcoming use of ICD-10 diagnostic code sets in claims submission, which is scheduled for implementation on October 1, 2013. HIPAA 5010 calls for the claims formats currently used (4010A) to be upgraded to 5010.

Psychologists generally file electronic claims in two ways: directly to the website or portal of a third party payor, or through a clearinghouse. We expect that most large third-party payors and clearinghouses have already updated their systems to be compliant with HIPAA 5010.

You may want to check with your smaller vendors to determine if they have completed the updates as well. You should be able to determine this information by contacting the carrier or checking the provider section of its website. 

One of the larger clearinghouses, Relay Health, claims to have already become 5010 compliant. Therefore, you should see no change in your submissions come January 1, 2012 if you are already filing electronic claims through them. Psychologists who find that their clearinghouses or vendors are not 5010 compliant may want to switch to another vendor. 

Lance Laurence, PhD, director of professional affairs for the Tennessee Psychological Association, provides an example from the field reflecting on progress with HIPAA Version 5010 compliance in Tennessee. He notes that carriers such as Magellan, United Behavioral Health, Aetna and Medicare have their own sites and claims are filed directly via the site. These carriers have upgraded to the new 5010 standards so if psychologists in Tennessee already file electronic claims directly with these carriers, they will see no changes in January 2012. 

What Should Psychologists Do Now to Prepare?

Contact your vendors, payers, billing services and clearinghouses to inquire about their upgrades to 5010 and when they will be ready to accept claims with the 5010 electronic format. If you are using a clearinghouse (instead of filing claims directly with the payor), you should check with the clearinghouse and/or software vendor regarding upgrades that you may need for your professional management software or electronic health records software to ensure compliance with the 5010 standards and make the necessary changes.

CMS update on Enforcement

As noted earlier in this article, CMS recently released an informational bulletin on enforcement of compliance with HIPAA 5010. CMS announced that while HIPAA 5010 compliance standards are still slated for a January 1, 2012 start date, they will not initiate enforcement actions with respect to HIPAA covered entities that are not compliant with the 5010 version until 90 days after January 1, 2012.

Additional Resources

Relay Health

CMS FAQs on 5010

For more information, contact the Legal and Regulatory Affairs department at (202) 336-5886 or by email.


Please note: Legal and technical issues are complex and require expertise that cannot be provided by any single article. The information in this article does not constitute legal advice and should not be used as a substitute for obtaining personal legal and technical advice and consultation prior to making decisions regarding individual circumstances.