So,  as promised earlier,  I am back here to furnish necessary information to all the readers on Healthcare transactions (5010) and Pharmacy claims (D.0). The mission is to enable the ultimate end users understand the basis of key elements of introducing modifications in existing versions. Such an attempt would extend tremendous help to all of them in transforming their existing software applications & systems, processes and procedures in a successful manner specified by the CMS.

Thus, let’s understand both of the versions separately:

I- Health Care Transactions (version 5010):

The version 5010 of the HIPAA standards includes improvements in structural, front matter, technical and data content (such as improved eligibility responses and better search options). This version supports both kinds of data, i.e., continuous as well as discreet. Thus, all forms of data that is required for carrying out any transaction either successful or unsuccessful implies to the newly built application. Successful transactions can be tightened, clear situational rules, etc while unsuccessful transactions can be corrections & reversals in claims processing, refund processing, recoupments, etc.

Furthermore, the new healthcare transactions not only focus primarily on claims but also contain significant improvements for reporting of clinical data. The reporting is based on codes- diagnosis or procedural. Both of the codes help us to distinguish in between principal diagnosis or admitting diagnosis or external cause of injury or reasons for patient visits. Hence, the availability of such compiled data will deliver better monitoring and efficient service. This would certainly help in keeping a regular check on mortality rates for certain illnesses, positive outcomes for specific treatment options, general reasons for seeking hospital care by Patients in their past records, and many more.

At last, version 5010 also addresses a variety of currently unmet business needs in the whole of Healthcare Value Chain. The transformation will provide a sigh of relief to all Patients seeking quality care in a highly secured environment followed by quick reimbursements by the CMS.

II- Pharmacy Claims (version D.0):

The new NCPDP version D.0 specifically deals with the business requirements that have originated on account of the implementation of the Medicare prescription drug benefit (Part D) as well as changes within the health care industry. With the introduction/insertion of new data elements and rejection codes, the processing time of both the ordinary claims and Part D claims would get reduced. Eventually, this will bring better control and coordination among the involved players.

Features of the version D.0:

• Version D.0 provides more complete eligibility information for Medicare Part D and other insurance coverage.
• Version D.0 identifies the patient responsibility in a better way, benefits to stages and coverage gaps on secondary claims.
• Facilitates the billing of multiple ingredients in processing claims for compounded drugs.

The compliance date for implementing Version 5010 and Version D.0 is January 1, 2012. The time gap would allow us to test the standards internally and ensure that the systems have been appropriately updated. Therefore, if require, the transitioning to the new formats could occur between the trading partners before the compliance date.

In addition, the general compliance date for the Medicaid pharmacy subrogation standard is also January 1, 2012. Although, the compliance date for some exceptional small health plans in pharmacy is extended for one more year.