HIPAA: General

  1. Do providers need to re-enroll in the Medi-Cal program?

    No. Current providers will remain in the Medi-Cal program with current information housed in the Provider Master File. If a provider’s name, address, National Provider Identifier (NPI), atypical provider legacy number or other pertinent information has changed, providers should review the Provider Enrollment area of the Medi-Cal website for instructions.

  2. Do providers need to complete a new Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153)?

    Providers currently approved to submit transactions electronically to Medi-Cal will not need to complete new paperwork. A Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) is required for providers who are:
    • Not currently submitting transactions electronically.
    • Submitting claims on multiple media. Providers must submit an individual application/agreement form for each media format used.
    • Changing their name or provider number. A new submitter number is required and a new application/agreement form must be submitted.
  3. Will the implementation of the HIPAA 5010 standards affect the telephone Automated Eligibility Verification System/Supplemental Automated Eligibility Verification System (AEVS/SAEVS)?

    No. The telephone Automated Eligibility Verification System/Supplemental Automated Eligibility Verification System will not be affected by the implementation of Version 5010.

  4. Will the providers that bill through a clearinghouse be required to link themselves to the clearinghouse's submitter ID?

    No. That linkage will already exist. Proper written notification is required under the following circumstances:

    • Provider Changes from Billing Service to Direct Submission
      Either the provider or the billing service must submit a letter identifying the billing service and provider numbers involved as well as the termination date. The provider must submit a new Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153). The provider must then be approved as a Computer Media Claims (CMC) submitter before claims may be submitted through CMC.
    • Provider Changes from Direct Submission to Billing Service
      A letter that provides the submitter's number, name, and the billing service address is required. The billing service must submit a new Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153).
  5. Will anesthesia billing be affected by the Version 5010 standard?

    Providers who bill electronically for anesthesia will be required to submit in minutes; units will no longer be accepted. In addition, start and stop times are no longer required. There are no changes to billing anesthesia via paper claims; submission and processing continue as before.

  6. Will the implementation of the ASC X12N 5010 and NCPDP D.0/1.2 formats affect my NPI?

    The Technical Reports Type 3 (TR3s) require that the reporting of the NPI is consistent to all trading partners (health plans, clearinghouses, affected vendors, and business associates). Version 5010 requires uniformity; the same NPI must be sent to every payer for the same service.

  7. Has NPI subpart usage changed in the ASC X12N 5010 format?

    For Version 5010 transactions, only an actual health care provider’s NPI (whether an organization, organization subpart, or individual) may be presented as the billing provider. If the rendering provider (and/or service location provider) NPI represents an organizational provider, then it must be an entity external to the billing provider.

    Individuals with a Type 1 NPI are allowed to be the billing provider only when the services were performed by, and will be paid to, an independent, non-incorporated individual. There is no change to the rendering provider when the billing provider is a physician practitioner group. The information of the individual practitioner who rendered the service will continue to be sent in the rendering provider loop with the Type 1 NPI used to identify them.

  8. Will diagnosis and surgical codes for ICD-10-CM be addressed in the Version 5010 update?

    To accommodate ICD-10-CM codes, the maximum number of diagnosis codes that can be reported on a claim has increased from 8 to 12. Diagnosis type code qualifiers have increased from two to three bytes; ABK, a technical qualifier code, has been added to support ICD-10-CM diagnosis codes. ICD-10-CM codes will be effective for dates of service on or after October 1, 2015. Continue to use ICD-9-CM codes until October 1, 2015.

  9. Will claim adjustments and voids be affected?

    No. Submissions will continue using the paper Claim Inquiry Form (CIF) process.

  10. How do providers in rural locations know what their "street address" is?

    Providers need to report their physical street address (not a P.O. Box or lock box) in the billing provider loop. If you are unsure what to report, the local post office can provide the street address or best description of the physical location.

  11. What is Version 5010 of the HIPAA X12 transaction mandate?

    HIPAA X12 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 X12 version 5010A1. Use of the new version 5010 of the X12 standards on or after the compliance date is required by federal law.

    Version 5010 accommodates ICD-10-CM values, whereas version 4010A1 did 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 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
  12. What are NCPDP D.0 and 1.2 batch versions?

    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 replaced 5.1, and 1.2 replaced 1.1.
  13. Who will need to upgrade to the HIPAA 5010 and NCPDP D.0 and 1.2 standards?

    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.

  14. What transactions are specified in the HIPAA mandate?

    The following provider-related transactions processed in CA-MMIS are specified in the standards:

    Transaction Type


    Previous Version

    New Current 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

    * X12 errata published July 30, 2010; X12 errata and NCPDP corrections mandated
    October 13, 2010 via notice in the federal register.

    The new X12 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.

  15. How can providers and other covered entities prepare for the transition?

    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. The NCPDP standards can be purchased at www.NCPDP.org.
  16. I bill using paper claims, does this affect me?

    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.