HIPAA Transition from 4010A to 5010 – Part 2 of 3

Why the change from 4010A to 5010?

Key issues for adapting HIPAA 5010 rules are:

  • To accommodate ICD-10 coding.
  • 4010 technology is outdated. It has been in use for five years and was written three years prior to that.
  • Many of the situational and required rules did not fit health care industry practices. This is especially true for the 278, where many entities had reply on companion guides and thus became non-standard.
  • Over 500 change requests are included in 5010.
  • Most rules in 5010 are the same in all transactions and are more consistent.
  • Includes D.0 of the NCPDP transactions for retail pharmacies.
  • Adapts version 3.0 of the NCPDP for subrogation of Medicaid pharmacy payments.
  • Clear rules will reduce analysis, time and minimize need for companion guides.
  • Improved eligibility responses and better search options will improve efficiency and reduce phone calls.
  • Clarification of misunderstood areas resulting in consistent implementation of 835 (Remittance Advice).

The X12 5010 transactions are meant for administrative communications between trading partners. These administrative communications include Claims, Enrollment, Eligibility, Claim Status, and Auths and Referrals.

5010 ushers in improvements in structural, front matter, technical, and data content (such as improved eligibility responses and better search options). The adjustments required for the 5010 transactions to enable them to facilitate the ICD-10 codes are simple. Space for expanded code length and additional instances of diagnoses need to be added. Space for a single digit code indicating the version of ICD codes being billed needs to be added also.

HIPPA5010 – Changes


  • Enrollment subtotals and reporting categories
  • Improved privacy protections
  • New Maintenance Reason Codes and policy amount qualifiers

Premium Payment

  • Addition of Outer Adjustment Loop
  • Additional deductions and payment reporting
  • Added Remittance Delivery Method

Eligibility & Benefits Inquiry Response

  • Unique ID to clarify subscriber and dependent relationship
  • Subscriber ID required on later translations (278, 837, etc.)
  • Requires support of different search options
  • 45 Service Type Codes added to support queries

Pre-Authorizations & Referrals

  • Event Level Detail Reporting includes info on conditions
  • Expanded Service Level Detail
  • External Code Set – Rejection Reason
  • Reconsideration Process

Claims – Professional, Institutional, and Dental

  • Attending Physician defined in new usage rule
  • Pay-to Address changed only when different from Billing Provider
  • Billing Providers carry NPI as Primary Identifier & must be same for all payers
  • Rendering Provider added to Institutional Claims
  • Patient/Subscriber reporting changed
  • POA indicators on Institutional Claims moved from K3 to HI
  • Separate HI segments for Principal, Admitting, E-Codes and Patient Reason Codes

Claims Status Inquiry and Response

  • Prescriptions and NDC numbers reporting allowed
  • Claim Status Codes and Multiple Claim Identifiers allowed
  • Modification of Subscriber and Dependent rules


  • Policy Information can be reported for Denials, Appeals, and Corrections
  • Additional Information on Technical Contact and Payer Website allowed
  • Clarity for Claims Overpayment Recovery and Balancing Added
  • Remark Code usage in connection with Reason Codes
  • HIPAA 5010 Transaction

For side-by-side comparisons between the 4010 and 5010 codes, click here.