These new versions address a variety of unmet business needs and concerns that were not thoroughly analyzed during earlier versions. The implementation of HIPAA 5010/ D.0 would require health plans to bring substantial changes to its business policies, processes and systems that submit claims, receive remittances, exchange claim status, maintain membership, pricing details etc.

1. February 2010
HIPAA 5010 – Systems Impacts

2. HIPAA 5010 – Systems Impacts | February 2010
Current Scenario
The Center for Medicaid and Medicare Services (CMS) requires the
health plans to adopt modifications to the HIPAA electronic transaction
standards published on Jan 16, 2009, for exchanging healthcare specific
administrative and financial transactions. The current version adopted
by the industry is ASC X12 Version 4010A1 for healthcare transactions
and NCPDP Version 5.1 for pharmacy transactions. Health plans are
now required to implement recently published HIPAA version 5010
and NCPDP D.0 standards by Jan 1, 2012.
These new versions address a variety of unmet business needs and
concerns that were not thoroughly analyzed during earlier versions.
The implementation of HIPAA 5010/ D.0 would require health
plans to bring substantial changes to its business policies, processes
and systems that submit claims, receive remittances, exchange claim
status, maintain membership, pricing details etc.
HCL with its wide IT service portfolio uses ediTTM 5.1 solution
to help the health plans transition to HIPAA 5010 standards.
HIPAA 5010 Changes Summary
There are more than 3500 individual changes that have to be implemented
across the enterprise. These changes are complex and require health plans
to upgrade their systems, processes, databases etc. Figure 1.1 demonstrates
the volume of changes in HIPAA version 5010 transactions.
Changes in version 5010 can be categorized into four categories:
Front matter, Technical improvements, Structural and Data content
changes. HCL has studied the 5010 implementation guides in detail
and evaluated the changes across different transactions. Based upon
the complexity associated with each change, HCL has analyzed its
impact on different processes and applications across health plan.
Table below describes the summary of changes between HIPAA
4010A1 and 5010 for each transaction type.
Figure 1.1
Figure 1.2
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3. HIPAA 5010 – Systems Impacts | February 2010
There are many modifications to the physical components of the
transaction which would lead to system enhancements, database changes
and report changes.
Impact Changes
System Impact Application changes Field length expansion
Business logic change
Change in screen inputs
New elements
Database changes Addition/deletion of elements
Code value changes
Field length expansion
Interfaces User interface changes
Modification to EDI interfaces
External applications
interfaces
Report changes New fields Report layout
Data Impact Data conversion
Other Impact Business policies and processes
Dual standard support during transition
HIPAA 5010 – Systems Impact
5010 changes have impact on policies, processes and applications across
a health plan. HCL’s understanding of the health plan’s IT landscape
facilitates the identification of impact of 5010/ D.0. Impact analysis output
details out the modifications required for seamless implementation of
changes in systems, processes and applications. This ensures a smooth
transition to HIPAA 5010/D.0 with minimal disruption.
Business Functions Entities
HCL has done the initial assessment for each HIPAA transaction
type for identifying the impacted business areas and entities across
health plans. In the table below, “ ” represents the impacted business
areas and entities across all transaction types and “ ” represents the
non impacted areas and entities.
X12 Transactions 270 271 278 837 835 276 277 834 820
Electronic data interchange
Electronic Medical Records
Authorization Management
Electronic Commerce
Federal Regulations Management
Data Analytics
Member Benefits
NCQA Accrediation
Business Areas
Claims adjudication
Claims payable
Providers network Management
Provider Reimbursement
Recovery and settlement
Fee Schedule
Utilization Management
Case Management
Accounting
Member Services
Accounts receivable
© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.
Member Billing
Affiliation

4. Claims payable
Business
Providers network Management
Provider Reimbursement
HIPAA 5010 – Systems Impacts | February 2010
Recovery and settlement
Fee Schedule
Utilization Management
X12 Transactions
Case Management 270 271 278 837 835 276 277 834 820
Accounting
Electronic data interchange
Member Services Records
Electronic Medical
Accounts receivable
Authorization Management
Member Billing
Electronic Commerce
Federal Regulations Management
Affiliation
Data Analytics
Provider
Payer Benefits
Member
NCQA Accrediation
Admission
Impacted Entities Areas
Claims adjudication
Employer
Claims payable
Member
Business
Providers network Management
Address
Provider Reimbursement
Group Practice
Service and settlement
Recovery
Fee Schedule
Claim Information
Contract Management
Utilization
Case Management
Authorization
Accounting
Receipt Information
Member Services
Invoice Info
Accounts receivable
Claim Check
Member Billing
Procedure
Drug Detail
Affiliation
Provider
Payer
Application components
Admission
Employer
Table below describes the impact of HIPAA 5010 changes on
Member
health plans application components. This is described using 270
Impacted Entities
Address
transaction as an example, this is sent from providers to health plans
Group Practice
to enquire about the health care benefits and eligibility associated
Service
with a subscriber or dependent.
Claim Information
Contract
HCL has similar analysis done for all the other HIPAA 5010
Authorization
mandated Information
Receipt transactions.
Invoice Info
Claim Check
HIPAA Element Element Segment Description
Data Migration / Update
Procedure
5010 Identifier Description
Database Changes
External Interface
Business Logic
Changes Detail
Drug
Reports
UI
Segment HI Subscriber      
added Healthcare Diagnosis
Code
AMT Subscriber Spend      
Down Total Billed
Amount
HI Dependent      
Healthcare Diagnosis
Code
Segment PER Info receiver contact      
deleted info
Change BHT03 Reference Beginning of      
in Field Identification hierarchical
Length transaction
NM103 Name Last or Information Source      
Organization Name
Name
NM104 Name First Information Source      
Name
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5. HIPAA 5010 – Systems Impacts | February 2010
HIPAA Element Element Segment Description
Data Migration / Update
Database Changes
5010 Identifier Description
External Interface
Business Logic
Changes
Reports
UI
Change NM103 Name Last or Info Receiver Name      
in Field Organization
Length Name
NM104 Name First Info Receiver Name      
REF02 Reference Info Receiver Addn      
Identification identification
PRV03 Reference Info receiver provider      
Identification info
TRN02 Reference Subscriber Trace      
Identification Number
TRN03 Reference Subscriber Trace      
Identification Number
NM103 Name Last or Subscriber Name      
Organization
Name
NM104 Name First Subscriber Name      
REF02 Reference Subscriber add      
Identification identification
PRV03 Reference Provider Information      
Identification
REF01 Reference Subscriber add info      
Identification
Qualifier
TRN02 Reference Dependent Trace      
Identification Number
TRN04 Reference Dependent Trace      
Identification Number
NM104 Name Last or Dependent Name      
Organization
Name
NM105 Name First Dependent Name      
REF02 Reference Dependent Add      
Identification Identification
PRV03 Reference Provider Information      
Identification
REF02 Reference Dependent Additional      
Identification Info
Code ISA11 Interchange Interchange Control      
Value Control Header
Added/ standards ID
Deleted
ISA12 Interchange Interchange Control      
Control Version Header
No
GS01 Functional Functional Group      
Identifier Code Header
GS08 Version/ Functional Group      
Release/ Header
Industry
identifier code
BHT02 Transaction Set Beginning of      
Purpose Code hierarchical
transaction
BHT06 Transaction Beginning of      
Type Code hierarchical
transaction
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6. HIPAA 5010 – Systems Impacts | February 2010
HIPAA Element Element Segment Description
Data Migration / Update
Database Changes
5010 Identifier Description
External Interface
Business Logic
Changes
Reports
UI
Code PRV02 Reference Info receiver provider      
Value Identification info
Added/ Qualifier
Deleted
NM108 Identification Subscriber Name      
Code Qualifier
REF01 Reference Subscriber add      
Identification identification
Qualifier
PRV01 Provider Code Provider Information      
DTP01 Date Time Subscriber Date      
Qualifier
EQ01 Service Type Subscriber Eligibility/      
Code Benefit enquiry Info
EQ03 Coverage Subscriber Eligibility/      
Level Code Benefit enquiry Info
EQ04 Insurance Type Subscriber Eligibility/      
Code Benefit enquiry Info
III01 Code list Subscriber Eligibility/      
Qualifier Code Benefit add enquiry
Info
III02 Industry Code Subscriber Eligibility/      
Benefit add enquiry
Info
DTP01 Date/Time Subscriber Eligibility/      
Qualifier Benefit Date
DTP03 Date Time Subscriber Eligibility/      
Period Benefit Date
REF01 Reference Dependent Add      
Identification Identification
Qualifier
PRV01 Provider Code Provider Information      
PRV02 Reference Provider Information      
Identification
Qualifier
DTP01 Date/Time Dependent Date      
Qualifier
EQ Service Type Dependent Eligibility/      
Code Benefit enquiry Info
EQ03 Coverage Dependent Eligibility/      
Level Code Benefit enquiry Info
EQ04 Insurance Type Dependent Eligibility/      
Code Benefit enquiry Info
III01 Code List Dependent Eligibility/      
Qualifier Code Benefit add enquiry
Info
Element DTP01 Date Time Dependent Eligibility/      
Added Qualifier Benefit Date
DTP03 Date Time Dependent Eligibility/      
Period Benefit Date
III01 Industry Code Dependent Eligibility/      
Benefit add enquiry
Info
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7. HIPAA 5010 – Systems Impacts | February 2010
HIPAA Element Element Segment Description
Data Migration / Update
Database Changes
5010 Identifier Description
External Interface
Business Logic
Changes
Reports
UI
Element ST03 Implementation Transaction Set      
Added Convention Ref Header
NM112 Name Last or Information Source      
Organization Name
Name
NM112 Name Last or Info Receiver Name      
Organization
Name
N407 Country Info receiver city/      
Subdivision state/ zip code
Code
NM112 Name Last or Subscriber Name      
Organization
Name
N407 Country Subscriber city/ state/      
Subdivision zip code
Code
DMG10 Code List Subscriber      
Qualifier Code Demographic
Information
DMG11 Industry Code Subscriber      
Demographic
Information
EQ02- Product/ Subscriber Eligibility/      
08 Service ID Benefit enquiry Info
EQ05 Composite Subscriber Eligibility/      
Diagnosis Benefit enquiry Info
Code Pointer
NM112 Name Last or Dependent Name      
Organization
Name
N407 Country Dependent State/      
Subdivision City/Zip Code
Code
DMG10 Code List Dependant      
Qualifier Code Demographic
Information
DMG11 Industry Code Dependant      
Demographic
Information
EQ02-8 Product/ Dependent Eligibility/      
Service ID Benefit enquiry Info
EQ05 Composite Dependent Eligibility/      
Diagnosis Benefit enquiry Info
Code Pointer
Usage NM103 Name Last or Information Source      
Change Organization Name
Name
NM103 Name Last or Info Receiver Name      
Organization
Name
N402 State or Info receiver city/      
province code state/ zip code
N403 Postal Code Info receiver city/      
state/ zip code
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8. HIPAA 5010 – Systems Impacts | February 2010
HIPAA Element Element Segment Description
Data Migration / Update
Database Changes
5010 Identifier Description
External Interface
Business Logic
Changes
Reports
UI
Usage PRV02 Reference Info receiver provider      
Change Identification info
Qualifier
PRV03 Reference Info receiver provider      
Identification info
N401 City Name Subscriber receiver      
city/ state/ zip code
PRV02 Reference Provider Information      
Identification
Qualifier
PRV03 Reference Provider Information      
Identification
EQ04 Insurance Type Subscriber Eligibility/      
Code Benefit enquiry Info
AMT02 Monetary Subscriber spend      
Amount down amount
N401 City Name Dependent City/      
State/ Zip code
PRV01 Provider Code Provider Information      
PRV02 Reference Provider Information      
Identification
Qualifier
PRV03 Reference Provider Information      
Identification
EQ03 Coverage Dependent Eligibility/      
Level Code Benefit enquiry Info
EQ04 Insurance Type Dependent Eligibility/      
Code Benefit enquiry Info
Name ISA11 Interchange Interchange Control      
Change Control Header
standards ID
BHT04 Date Beginning of      
hierarchical
transaction
INS Subscriber Subscriber      
Relationship Relationship
INS06 Medicare Plan Subscriber      
Code Relationship
HCL has a complete knowledge base of impacted policies,
processes, applications and the impacted entities in a health plan.
This knowledge will enable faster understanding of the existing
landscape and transition to desired TO-BE state meeting the
federated timelines.
© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.

9. HIPAA 5010 – Systems Impacts | February 2010
Why HCL?
TM
• HCL ediT 5.1 solution covers methodologies for Enterprise
discovery, Impact Analysis, System enhancements, Testing and
Transition Support for HIPAA 5010 and NCPDP D.0
• Solution architects and consultants experienced in X12N
4010A1/5010 and NCPDP D.0 standards
• Existing knowledge base for impacted policies, business processes,
work flows, people, entities and fields
• Testing toolkit READY; compliance and trading partners
• Center of Excellence for leading B2B and EDI platforms
• Subject matter experts in Payer and Provider business processes
• Dedicated HIPAA security and privacy (GRC) consulting practice
• HCL has a HIPAA security and privacy consulting practice
• Certified consultants in HIPAA from HIPAA Academy, USA
– Certified HIPAA Professional
• Footprint across major healthcare Clients including: One of the
largest Blue Cross Conglomerates, Regional Health Plan, Leading
Diagnostic Company, Leading HMO
Authors
Narender Dureja is Practice Director – Healthcare
at HCL Technologies Ltd. He is a certified
professional in hospital information management
systems. Narender had been involved in crafting
solutions for different industry verticals for the
last 20 years. He currently drives the HIPAA
5010 solution at HCL.
Mahima Bahri is Senior Consultant – Healthcare
at HCL Technologies Ltd. She is a Certified
HIPAA Professional. She has worked on
multiple areas within healthcare domain and
is currently engaged in building HIPAA 5010
solution for HCL.
© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.

10. 10
HIPAA 5010 – Systems Impacts | February 2010
ABOUT HCL
HCL Technologies
HCL Technologies is a leading global IT services company, working
with clients in the areas that impact and redefine the core of their
businesses. Since its inception into the global landscape after its
IPO in 1999, HCL focuses on ‘transformational outsourcing’,
underlined by innovation and value creation, and offers integrated
portfolio of services including software-led IT solutions, remote
infrastructure management, engineering and RD services and
BPO. HCL leverages its extensive global offshore infrastructure
and network of offices in 26 countries to provide holistic, multi-
service delivery in key industry verticals including Financial
Services, Manufacturing, Consumer Services, Public Services and
Healthcare. HCL takes pride in its philosophy of ‘Employee First’
which empowers our 55,688 transformers to create a real value
for the customers. HCL Technologies, along with its subsidiaries,
had consolidated revenues of US$ 2.5 billion (Rs. 11,833 crores),
as on 31st December 2009 (on LTM basis). For more information,
please visit www.hcltech.com
About HCL Enterprise
HCL is a $5 billion leading global Technology and IT Enterprise
that comprises two companies listed in India - HCL Technologies
HCL Infosystems. Founded in 1976, HCL is one of India’s
original IT garage start-ups, a pioneer of modern computing, and
a global transformational enterprise today. Its range of offerings
spans Product Engineering, Custom Package Applications,
BPO, IT Infrastructure Services, IT Hardware, Systems
Integration, and distribution of ICT products across a wide range
of focused industry verticals. The HCL team comprises over
60,000 professionals of diverse nationalities, who operate from
26 countries including over 500 points of presence in India. HCL
has global partnerships with several leading Fortune 1000 firms,
including leading IT and Technology firms. For more information,
please visit www.hcl.in
© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.