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Achieving HIPAA 5010 Compliance

with Edifecs

S O L U T I O N B R I E F
 Healthcare Industry Overview
The exorbitant cost of healthcare in the U.S. has been the topic of many debates and published reports. One of the most
1
comprehensive reports on the subject was prepared for the U.S. Congress comparing U.S. healthcare costs to those of other nations
in the OECD (Organization for Economic Cooperation and Development, a group of 31 countries). This report noted that the U.S.
spends $6,103 per capita, which was more than double the OECD average. Healthcare spending as part of the GDP in 2004 was
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15.3% for the US while the OECD average was 8.9%.
The report also analyzed measures of health outcomes and concluded that the US has a shorter life expectancy, higher than average
mortality rates, greater infant mortality rates and limited access to care for same day appointments along with night and weekend
doctor visits. This data suggests that even though the US spends much more than the average of the OECD countries, the benefits
realized are limited at best.

Why HIPAA?
The motivation behind HIPAA was to implement standards that reverse the negative cycle of increased cost and decreased benefits
in the U.S. healthcare system. Since 2002, the industry has overseen the implementations for Privacy, ASC X12 4010-A1 transaction
sets, Security, National Employer Identifier and National Provider Identifier (NPI). Most recently Congress passed into law two new
standards: Updating electronic standards from 4010A1 to 5010 and conversion of ICD-9 codes to ICD-10. By January 1, 2012
all covered entities must be able to send and receive all HIPAA transactions in the 5010 format. Immediately following 5010, the
industry must be ready to convert from ICD-9 to ICD-10 by October 1, 2013.
Healthcare organizations seeking to implement ASC X12 5010 and ICD-10 face funding and resource issues; these organizations
also need to tackle the more complex challenge of fitting these mandates with overall corporate strategies. Considerations for 5010
implementation need to include the understanding of new information contained in 5010 and how best to use this data. ICD-10
conversion is much broader and will require deep planning and coordination between trading partners.

HIPAA 5010
The effort required for HIPAA 5010 is a “good HIPAA Transactions X12 TR3 Volume of
Standard Changes
news - bad news” story. The good news is that
unlike the 4010-A1 implementation, 5010 Enrollment 834 X220 117
theoretically should be an upgrade from X12 Premium Payment 820 X218 23
to X12. However, what also must be taken Eligibility & Benefits Inquiry & Response 270 & 271 X279 143
into account are the business rule changes Authorization 278 X217 277
that may have a bigger impact. Claims – Professional 837 X222 265
Claims – Insitutional 837 X223 152
A few examples include billing provider
Claims – Dental 837 X224 190
rules on claim submissions, COB information
requirements reported on the remittance Claim Status Inquiry & Response 276 & 277 X212 76
advice, and specific benefit and liability Remittance 835 X221 88
information returned on eligibility inquires. Total 1,331
Table 1 shows a summary of changes between
Table1
4010-A1 and 5010 for each transaction. Summary of Changes between HIPAA 4010A1 and 5010 by Transaction Type

1
“CRS Report for Congress: US Healthcare Spending Comparison with other OECD Countries” – Chris L. Peterson and Rachel Burton, Domestic
Social Policy Division – September 17, 2007
2
IBID

Achieving HIPAA 5010 Compliance

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with Edifecs
Options for Achieving HIPAA 5010 Compliance
There are 3 basic strategies for implementing 5010:

• Complete replacement of systems: This strategy is
appropriate when the 5010 and ICD-10 changes are
significant enough to require complete replacement of the
entire claims processing system for the health plan. This
would include the adjudication (claims processing) function,
intake (EDI Gateway), user interfaces and reporting systems.
• Remediation: This strategy implies making enhancements
to core processing (or back-end) systems to meet HIPAA 5010
and ICD-10 compliance while at the same time upgrading
the front-end systems (Gateway component) in order to
process 5010 transactions and ICD-10 code sets.
• Step Up / Step Down: This strategy requires making
changes to the intake system of transactions (Gateway
component) such that the inbound transactions are mapped
or transformed from the 5010 transaction set to the 4010A1
transaction set and then passed downstream leaving the
complete processing engine intact. In addition, outbound
transactions are converted back to 5010 before being sent
to trading partners. This strategy would limit the scope and a
remediation effort as the transactions being processed would
continue unchanged. (If you are interested in learning more
about Edifecs’ approach to this topic, please see the Edifecs Step-
Up / Step-Down Solution Brief.)

How Can Edifecs Help

Edifecs’ Healthcare offerings help achieve compliance with current mandates such as HIPAA 5010 with a suite of products that
allows for improved governance and control of implementation and production costs. Given that the January 1st, 2011 deadline for
compliance Level 1 is looming large, Edifecs recognizes that the focus of many organizations is to implement a compliant solution
while keeping risk, scope and costs under control. In order to meet these objectives, Edifecs offers products and solutions that
enable organizations to achieve HIPAA 5010 compliance, regardless of the implementation strategy being adopted.
A schematic showing Edifecs products and solutions is shown in Figure 1.

Figure 1: Edifecs Healthcare Offerings

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with Edifecs
 The Edifecs Healthcare Product Suite
The Edifecs Healthcare Product Suite includes three product lines – Unified Testing™, Unified Compliance™ and Unified Visibility™.
Together, these three product lines make up the Edifecs Unified Channel™ solution for modernization of the information processing
(channels) infrastructure. Given the pervasive adoption of Edifecs’ solutions for testing, validation and on-going compliance, Edifecs
is considered the ‘Gold Standard’ for HIPAA certification and production compliance.

• Unified Testing™ provides a consistent, centralized, end-to-
end, collaborative and uniform way to on-board the entire
trading partner community of providers, submitters and
more. Edifecs Unified Testing™ covers guideline migration,
test data generation, internal testing, external testing,
• Unified Visibility™ allows full insight into all transaction
3rd party testing, connectivity testing and various others
steps required in moving partners from initial engagement
to ongoing production. Unified Testing™ consists of
Edifecs SpecBuilder, Edifecs Ramp Management and Edifecs
Compliance-Online.
• Unified Compliance™ provides a channel-independent,
centralized single front-end to ensure on-going compliance
of production information exchanged with trading
partners and between multiple business systems. Edifecs
Unified Compliance™ solution supports all file formats, all
standards and all versions of HIPAA including 5010. Unified
Compliance™ consists of Edifecs SpecBuilder (including
MapBuilder) and Edifecs XEngine (including Translator).
activity across all information processing channels. From
one centralized system, Edifecs enables full 360-degree
view into a transaction lifecycle from initiation to fulfillment
of that transaction. Edifecs provides a unique business
normalized repository of all transaction information. Unified
Visibility™ enables a “single source of truth” for transactional
information for internal as well as external users. Unified
Visibility™ includes the Edifecs Transaction Management and
Edifecs XEngine products.

Each of the products within the Compliance and the Visibility product lines provides extensive features and functionality to assist in
the HIPAA 5010 migration.

Edifecs5010™ Solution
The Edifecs5010™ solution uniquely combines the capabilities
of the Edifecs Healthcare Product Suite with free set of tools
available through Edifecs5010™ Compliance Online and
5010-specific consulting services to provide step-by-step
guidance for HIPAA 5010 migration and upgrade. (Figure 2)

The four products in the Edifecs Healthcare Product

Suite include Edifecs SpecBuilder, Edifecs Ramp Management, Figure 2: The Edifecs5010™ Solution
Edifecs XEngine and Edifecs Transaction Management. As
discussed previously, these four products also constitute the three product lines – Unified Testing™, Unified Compliance™ and
Unified Visibility™.

Edifecs SpecBuilder (SB) is an intuitive and powerful design-
time tool to create guidelines. Features include:
• MapBuilder – a design-time tool used to create and
edit mapping specifications between source and target
guidelines.
• Full standards reference for HIPAA 5010.
• Out-of-the-box 5010 guidelines with support for HL7 and
NCPDP standards.
• Ability to easily create, publish and share 5010 Companion
Guides.
• Ability to perform gap analysis between 4010A1 and 5010
standards.
• Ability to migrate 4010A1 edits to 5010.
• Ability to create 5010 test data from 4010A1 production data.
• Ability to carry the newly-created guidelines into the
production environment for transaction validation and
reporting.
Edifecs Ramp Management (RM) allows customers to on-
board trading partners and performs end-to-end scenario-
based 5010 testing. It is estimated that bringing on a new
partner like a provider or a clearing house can take between
two weeks and nine months. Ramp Management helps
automate the testing procedures and can significantly help
reduce the on-boarding time. Feature of this tool include:

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• Scenario-based 5010 testing for trading partners.
• Invitations for trading partners to self-test 5010 transactions.
• Partner scorecard for trading partner to self-assess 5010
testing progress.
• Dashboards, reports and interactive management tools to
manage the 5010 testing process with a large diverse trading
partner community.
Edifecs XEngine (XE) provides customers with run-time
validation, dual mode translation between 5010 and 4010
formats during testing and production, routing, splitting,
enriching and other message processing capabilities. XE
provides the following capabilities:
• Pre-built maps in both directions (5010 to 4010A1 and
4010A1 to 5010) for all HIPAA transactions.
• Help file that provides guidance about recommended
customer-specific settings in the pre-built maps.
• Dual support for both 5010 and 4010A1 based on a trading
partner profile, allowing processing of one partner on
4010A1 and another on 5010.
Edifecs5010™ Compliance Online provides a number of free resources and tools to facilitate the 4010A1 to 5010 migration.
• Edifecs5010™ Guidelines provide access to free HIPAA 5010
guidelines in an easy-to-use and simple-to-navigate format.
• Edifecs5010™ Comparison Manuals provide a side-by-
side comparison of the 4010A1 and 5010 HIPAA standard
changes, along with a business and technology impact
Figure 3: Sample Certificate Provided by the Edifecs5010™ Certification service
Edifecs’ Consulting Services employs world-class service professionals who are deeply conversant with HIPAA 5010 and
trained in the latest technologies. Edifecs Consulting Services can perform the following:
• Advise on an overall enterprise architecture leveraging HIPAA
5010 as an opportunity for channel modernization.
• Assist in the gap analysis between 4010A1 and 5010,
evaluate multiple options and recommend the best
approach to 5010 migration.
• Recommend the best strategy depending on organizational
Edifecs Transaction Management (TM) allows customers to
gain uniform visibility into 4010A1 and 5010 transactions in
production. TM provides the following capabilities:
• Easily locate and view both 4010A1 and 5010 formatted
transactions and business documents within a common user
interface.
• Report on inbound and outbound 5010 validation results
along with error analysis across multiple files and over
specified time periods; compare across trading partners and
core processing systems.
• Report on inbound and outbound flow of individual business
documents (e.g. claim, request, etc.) between trading
partners and the core processing system
• Associate outbound business documents with related
inbound documents.
• Archive inbound 5010 and outbound 5010 transmission
data in a file repository where they can be easily located and
viewed within the Transaction Management portal.
analysis by HIPAA experts.
• Edifecs5010™ Testing and Certification allows healthcare
organizations to perform full scenario-based testing and get
certified as part of the 5010 migration effort.
strategy, ranging from complete remediation to the Step-Up
/ Step-Down approach.
• Provide program management assistance to manage overall
execution of 5010 projects.
• Assist in deployment, training and overall change
management during the 5010 implementation.
Achieving HIPAA 5010 Compliance
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with Edifecs
 Figure 4 depicts how Edifecs products assist with getting to 5010 compliance. Each product addresses a specific challenge
or obstacle organizations will face as they move towards 5010. Edifecs products can eliminate many of these problems while
controlling budget and resource constraints.

Figure 4: Glide Path to 5010 Compliance

Conclusion
The healthcare industry faces a number of different challenges that will require efforts over an extended period of time from the U.S.
government and its agencies, healthcare providers, payers, pharmaceutical companies, services firms, software vendors and many
others.
The Edifecs Healthcare Product Suite addresses many of the challenges facing healthcare organizations by streamlining information
flow between healthcare entities and providing visibility into that information. Streamlining information flow and providing
business intelligence about healthcare-related information helps healthcare organizations proactively address many issues, helps
resolve issues quickly when they do arise and aids with continuous improvement in the healthcare value chain.
The Edifecs5010TM Compliance solution further helps healthcare organizations take control of their HIPAA 5010 migration
initiatives. The Edifecs5010TM Compliance solution helps organizations stay compliant while accelerating healthcare channel
modernization efforts.

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Notes

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About Edifecs
An industry leader since 1996, Edifecs provides healthcare software and solutions that
automate exchange of information between doctors, hospitals, insurance companies
and other healthcare organizations. Edifecs’ healthcare offerings enable compliance with
current mandates, improve governance through enhanced end-to-end visibility and
enhance operational efficiency by reducing costs.
Edifecs has over 350 healthcare customers that include Blue Plans, Medicaid, State and
Federal agencies, Healthcare Providers and partners such as IBM, Oracle, TIBCO, Informatica
and Axway.
Edifecs has been recognized as one of the 100 Fastest Growing Private Companies in
Washington state, 100 best places to work for in Washington state, and Inc5000 fastest
growing companies in the US. Edifecs’ CEO is a recognized business leader (40-Under-40).
Edifecs is headquartered in Bellevue, WA.

www.edifecs.com