Health Net: Stop, Think, Prepare for 5010

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News and Announcements Archive

Linda Hubbard Lalande, Howard Cohen

Oct. 3, 2011

Massive 5010 compliance project will move Health Net to more standardized electronic transactions

We’re changing how we handle many of our electronic transactions to meet this critical mandate by January 1, 2012. This is in response to the Department of Health and Human Services ruling to replace the HIPAA electronic standard 4010A1 with a new version 5010 by the first of the year. This change will improve how we meet the HIPAA requirement that covered entities in the health care industry implement and use mandated standards in the electronic transmission of health care transactions, such as claims, remittance advices, eligibility confirmations, and claims status requests and responses.

The HIPAA ruling has become a mandate of the Centers for Medicare and Medicaid Services (CMS). “This has been a very far reaching project, requiring careful coordination across the enterprise between associates, trading partners and our vendor partners Cognizant and IBM. We have been preparing for implementation since early 2010 through communications of these changes from the executive levels related to operational impacts and more recently at the detailed level, relative to changes to data elements that are used for reporting across the enterprise. This project gives us the foundation for the upcoming ICD-10 compliance initiative,” says Howard Cohen, 5010 Program Manager, ITG Business Engagement.

“5010 is the basic building block for other enhancements to improve the administration of health care benefits like coordination of benefits, enhanced policy holder demographics and medical management,” says HIPAA 5010 Project Sponsor Jaimee Hemphill, VP, Project Planning & Delivery, Portfolio Project Management Organization (PPMO).

The pending ICD-10 compliance initiative will enhance the reporting and administration of health care benefits through giving us the ability to capture more detailed sets of data, by adding new procedure and diagnostic code sets and increasing the number of occurrences of these codes. Look for more in this space on ICD-10 which began in Q3 2011, and is scheduled to complete by Q3 2013.

Connect the dots …

HIPAA 5010 is a major factor for Health Net to meet it’s Strategic Imperative of “Enhance Stakeholder Value: Achieve Compliance and Flexibility.”

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Why is the industry adopting this major change?

HIPAA administrators determined that certain national standards used in electronic transactions lacked certain functionality and consistency. The new HIPAA 5010 standard solves this dilemma. It is necessary to adopt 5010 in order for federally regulated trading partners to continue to exchange data electronically. Trading partners include providers, hospitals, clinics, pharmacies, clearinghouses and other entities exchanging electronic information.

What are the benefits?

One of the most notable advantages of 5010 will be the removal of ambiguities in the existing health care information processing systems, ensuring more consistency in health care transactions, ” explains Hemphill.

o 5010 enhances the existing standards and common interfaces, significantly improving the exchange of data. Trading partners will be able to more efficiently exchange information critical to the administration of health care, with enhanced Coordination of Benefits, Diagnosis and Procedure Codes.

o 5010 involves expanding the set of data transacted by adding and expanding fields needed for future health care administrative needs, resulting in increased efficiency and business opportunity.

o The implementation of HIPAA Version 5010 presents substantial changes in the content of the data that providers and other trading partners submit with their claims, as well as the data available to them in response to their electronic inquiries for eligibility or claims status.

Achieve Compliance and Flexibility



> Improvements include the following: o standardized business information o less confusing technical reports o more specific definitions of what data needs to be collected and transmitted o supports monitoring of certain illness mortality rates, outcomes for specific treatment options, hospital stays, and clinical reasons for care o improved information for coordination of benefits o more complete eligibility information o better identification of patient responsibility

Health Net’s 5010 compliance efforts

The 5010 project allows Health Net to become HIPAA Compliant with the new X12 Version 5010 transaction standards by 1/1/2012 as mandated by Centers for Medicare and Medicaid Services (CMS). The new regulations require conversion of all HIPAA regulated transactions and regulated entities exchanging these transactions by January 1, 2012.

With this implementation Health Net sets the foundation for future initiatives mandated by CMS including ICD-10. ICD-10 involves new coding and increases the number of occurances of codes.

5010 will involve the following Health Care Transactions:

o Claims and Encounters o Eligibility Request and Response o Claims Acknowledgement o Enrollment and Disenrollment in a Health Plan o Health Care Payment and Remittance Advice o Health Plan Premium Payment o Referral Certification and Authorization Request and Response

How will this affect associates?

“Basically, in the short term the implementation will retain existing business functionality and the changes that associates may see are the addition or expansion of certain fields in screens and reports. Longer term, as Health Net takes advantage of this richer data content, there will other initiatives to enhance our administrative processes,” says Cohen.

Management of the affected areas have been notified and are working with the 5010 team in respect to system impact. A Client Notification was sent out on 9/30/11 to managers and above announcing that the following systems will have planned downtimes on Friday, Oct. 7, 2011.

5010 Planned Downtimes on October 7th at 2:00pm PST



Stay tuned for ongoing 5010 updates as this major initiative heads toward completion by January 1, 2011

Timeline for 5010 and ICD-10 on the ITG Roadmap

"The scope of the 5010 project involved associates from many different departments as well as our vendor partners, IBM and Cognizant, to make the multitude of system enhancements to

support the new standards. Thank you to all those working diligently to implement this important initiative."

Howard Cohen, 5010 Program Manager, ITG Business Engagement

Jaimee Hemphill, HIPAA 5010 Project Sponsor, VP, Project Planning & Delivery, Portfolio Project Management Organization (PPMO)



Fact sheet:

5010 Basics

Factoid: Over 99% of Medicare Part A claims and over 96% of Part B claims transactions are received electronically.



Healthcare

Health Net: Stop, Think, Prepare for 5010