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Medicare FFS Updates

CMS' Medicare FFS program is underway with implementation activities to convert from Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version D.0.

The Medicare FFS program is engaged with both its internal and external partners to ensure compliance with the timelines provided in the 5010/D.0 final regulation.  The Office of Information Services (OIS), Business Applications and Management Group (BAMG), Division of Medicare Billing Procedures (DMBP) is coordinating 5010/D.0 implementation across CMS and its partners.

HHS permits dual use of existing standards (4010A1 and 5.1) and the new standards (5010 and D.0) from the March 17, 2009, effective date until the January 1, 2012 compliance date to facilitate testing subject to trading partner agreement.

The CMS Medicare FFS schedule:

  • Level I April 1, 2010 through December 31, 2010
  • Level II January 1, 2011 through December 31, 2011
  • Fully compliant on January 1, 2012

For further information on CMS' Medicare FFS 5010/D.0 Implementation activities go to HIPAA Eligibility Transaction System (HETS) Help (270/271) and, Medicare Fee-for-Service 5010 - D0

The Medicare FFS Approach

The purpose of this message is to clearly communicate the approach that Medicare Fee-For-Service (FFS) is taking to ensure compliance with the Health Insurance Portability and Accountability Act's (HIPAA's) new versions of the Accredited Standards Committee (ASC) X12 and the National Council for Prescription Drug Programs (NCPDP) Electronic Data Interchange (EDI) transactions.

The Standards Development Organizations have made corrections to the 5010 and D.0 versions of certain transactions. The Errata versions replace the Base versions for HIPAA compliance. Per the Federal Register (Vol. 75, No. 197, October 13, 2010, 62684–62686 [2010–25684] found at http://www.access.gpo.gov/su_docs/aces/fr-cont.html), HIPAA compliance will require the implementation of the Errata versions and the Base versions for those transactions not affected by the Errata, as listed below. Compliance with the Errata must be achieved by the original regulation compliance date of January, 2012.

Table 1. Transactions Affected by the Errata - list of Base and Errata versions for 5010 and D.0.

Transactions Affected by the Errata VersionBase VersionErrata Version
270/271 Health Care Eligibility Benefit Inquiry and Response005010X279005010X279A1
837 Health Care Claim: Professional005010X222005010X222A1
837 Health Care Claim: Institutional005010X223005010X223A2
999 Implementation Acknowledgment For Health Care Insurance005010X231005010X231A1
835 Health Care Claim Payment/Advice005010X221005010X221A1
276/277 Status Inquiry and Response005010X212N/A
277CA Claim Acknowledgement005010X214N/A
National Council for Prescription Drug Programs (NCPDP) Version D.0 of the Telecom StandardD.0D.0 April 2009

Medicare FFS will implement the Errata versions to meet HIPAA compliance requirements. Also in compliance with the published regulation (RIN 0938-AM50 of 45 CFR Part 162), Medicare FFS testing with external trading partners must begin in January of 2011.

CMS HETSHelp site

The CMS HETSHelp site provides information specific to the HIPAA Eligibility Transaction System (HETS) for 270/271 Medicare eligibility transactions. Please visit the HETSHelp site at: http://www.cms.hhs.gov/HETSHelp/ for details about the changes being made to HETS to support the X12 5010 standard.