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HIPAA 5010/NCPDP D.0 and 1.2 - Frequently Asked Questions (FAQs)

Updated November 1, 2011
  1. Q: What is Version 5010 of the HIPAA X12N transaction mandate?
    A: HIPAA X12N version 5010, commonly referred to as HIPAA 5010, is a new set of standards that regulates the electronic transmission of specific health care transactions, including the following transactions:
    • Eligibility inquiry and response
    • Claim status inquiry and response
    • Claim submission
    • Remittance advice

    Covered entities, such as health plans, health care clearinghouses and health care providers are required to comply with HIPAA standards. The current transaction standard is the X12N version 4010A1.

    Version 5010 accommodates ICD-10-CM (Clinical Modification) and ICD-10-PCS (Procedure Coding System) values, whereas version 4010A1 does not. The 5010 implementation guides or Technical Report – Type 3 (TR3) documents specify how the transactions should be formatted, the data content that is required and allowable, and the structure of the transaction.

    Version 5010 includes the following types of changes:

    • Consistency across transactions
    • Accommodation of ICD-10-CM and ICD-10-PCS values
    • New-use cases introduced by the health care industry
    • Clarification of usage to eliminate ambiguity
    • Removal of data content that is no longer used

  2. Q: What are NCPDP D.0 and 1.2 batch versions?
    A: HIPAA Version D.0 is the new National Council for Prescription Drug Programs (NCPDP) standard for Interactive Pharmacy Claims, eligibility inquiries and prior authorization. Version 1.2 is the new NCPDP standard for Batch Pharmacy Claims. Version D.0 will replace 5.1, and 1.2 will replace 1.1.

  3. Q: Who will need to upgrade to the HIPAA 5010 and NCPDP D.0 and 1.2 standards?
    A: The following covered entities that conduct any of the affected electronic transactions are required to comply with HIPAA 5010 and the NCPDP D.0 and 1.2 standards, and may use a clearinghouse to assist with compliance:
    Healthcare Providers including:
    • Physicians
      • Hospitals
      • Ancillary and behavioral health care providers, including nurse practitioners and nurse practitioner primary care providers
      • Pharmacies
      • Dentists
    • Payers/health plans
    • Health care clearinghouses

    Although software vendors are not included in the list of covered entities above, they will need to upgrade their products to support the new transaction versions.

  4. Q: What transactions are specified in the HIPAA mandate?
    A: The following provider-related transactions processed in CA-MMIS are specified in the standards:

    Transaction Type


    Current Version

    New Version


    Eligibility Benefit Inquiry/Response

    X12N 4010 X092 A1

    X12N 5010 X279 E1, A1 *


    Claim Status Request/Response

    X12N 4010 X093 A1

    X12N 5010 X212 E1, E2



    X12N 4010 X091 A1

    X12N 5010 X221 E1, A1 *

    837 I

    Claims: Institutional

    X12N 4010 X096 A1

    X12N 5010 X223 A1, E1, A2 *

    837 P

    Claims: Professional

    X12N 4010 X098 A1

    X12N 5010 X222 E1, A1 *

    NCPDP D.0

    Retail Pharmacy: Interactive

    NCPDP 5.1

    NCPDP D.0, republished August 2010 *

    NCPDP 1.2

    Retail Pharmacy: Batch

    NCPDP 1.1

    NCPDP 1.2

    * X12N errata published July 30, 2010; X12N errata and NCPDP corrections mandated
    October 13, 2010 via notice in the federal register.

    The new X12N version updates also impact the following transactions; however, CA-MMIS does not process these transaction types at this time:

    • 278 – Referral requests and responses
    • 837 D – Claims (dental); (these are processed at CD-MMIS)

    CA-MMIS is a pass-through for the following transactions to the Managed Care Plans, so modifications will be made at DHCS for these:

    • 820 – Premium payments
    • 834 – Enrollment and disenrollment in a health plan

    Information on transactions not currently in use in CA-MMIS such as the 999 and its impact on the 997, which is currently in use, will be addressed in future articles.

  5. Q: Why is it necessary to upgrade to the new HIPAA transaction versions?
    A: The upgrade to versions 5010, NCPDP D.0 and 1.2 is important because it is mandated by the federal government. The new versions will contain improvements and will also be able to accommodate the forthcoming and mandatory ICD-10-CM and ICD-10-PCS code sets, which are scheduled to be implemented for outpatient claims with dates of service, and inpatient claims with dates of discharge, on or after October 1, 2013.

  6. Q: How can providers and other covered entities prepare for the transition?
    A: Providers and organizations can prepare by reviewing the Technical Reports – Type 3 (TR3s) and NCPDP standards with their business partners, such as clearinghouses and software vendors. The TR3 documents are available for purchase from the Washington Publishing Company website (www.wpc-edi.com). The NCPDP standards can be purchased at www.NCPDP.org.

  7. Q: When will the companion guides be available?
    A: Revised companion guides were released October 1, 2011 and NCPDP Technical Specifications will be released to providers as soon as possible.

  8. Q: I bill using paper claims, does this affect me?
    A: At this time there is no anticipated HIPAA 5010-related impact to providers who bill on paper. However, further review of the impact of HIPAA 5010 on CA-MMIS may result in paper claims being affected. Those providers who bill using paper claims will be impacted once ICD-10-CM and ICD-10-PCS codes are mandated, effective for outpatient claims with dates of service, and inpatient claims with dates of discharge, on or after October 1, 2013.

  9. Q: What is the scheduled implementation date for ICD-10-CM?
    A: According to CMS compliance dates, implementation for ICD-10-CM and ICD-10-PCS is scheduled for outpatient claims with dates of service, and inpatient claims with dates of discharge, on or after October 1, 2013.

  10. Q: When will CA-MMIS accept HIPAA 5010 and NCPDP D.0 and 1.2?
    A: Implementation delays have occurred. Please visit the Medi-Cal Newsroom to view information regarding the delay.