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HIPAA 5010 Implementation

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The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves in order to:  
  • Create better access to health insurance
  • Limit fraud and abuse
  • Reduce administrative costs
  • Accommodates the ICD-10 set change effective October 1, 2013  

SDMC 5010 HIPAA-Compliant Transaction Standards to Change Effective January 1, 2012

On Jan. 1, 2012, the Short-Doyle/Medi-Cal (SDMC) system will accept claims in the 5010 format, per Federal Law.

The Departments of Health Care Services (DHCS), Mental Health (DMH), and Alcohol and Drug Program (ADP) have initiated a project to modify the SDMC system to accept and process the newly mandated HIPAA electronic transaction version 5010.

"Version 5010" is the abbreviated way to refer to "Version 005010 of the Accredited Standards Committee (ASC) X12 Technical Reports Type 3 (TR3s)". TR3s are the implementation guidelines for the ASC X12, some of which are named in HIPAA, and are required when conducting transactions electronically.

Effective January 1, 2012, the X12 4010A1 version currently in use will be updated to Version 5010. This update is required for all providers who submit administrative electronic transactions, such as checking a recipient’s eligibility, filing a claim, or receiving remittance advice details either directly or through a clearinghouse. The following transactions will be updated to adopt the new standards:

Transaction Type
Current Version
New Version
276/277 Claim Status Request/Response X12N 004010X093A1 X12N 005010X212E1
835 Payment/Advice X12N 004010X091A1 X12N 005010X221A1*
837 I Claims: Institutional X12N 004010X096A1 X12N 005010X223A2*
837 P Claims: Professional X12N 004010X098A1 X12N 005010X222A1*
999 Acknowledgment for Health Care Insurance 997 - 004010 X12N 005010X231A1*


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

For all other transactions used by Medi-Cal, such as the 270/271, please refer to the Medi-Cal website.                                  Back to Top

5010 Training

HIPAA 5010 Trading Partner Walk Through – (May 20, 2011 and June 9, 2011)

5010 Testing

On March 14, 2011, Short Doyle Medi-Cal Phase II (SDMC) system started accepting Health Care Claim: Professional (837P), Health Care Claim Institutional (837I), and Health Care Claim Status Request (276) transactions in 5010 form for 5010 SNIP validation testing in the County Test environment.  The SD/MCII 5010 DMH testing procedures are available at link below.

At this time, the SDMC system will not adjudicate 5010 test claims and 5010 835 files will not be returned.  4010 test claim will continue to be validated and processed through the entire SD/MCII testing environment, including returning 4010 835 results.

Implementation Timeline

On January 16, 2009, the federal Department of Health and Human Services (DHHS) announced that updated HIPAA-compliant versions of the electronic transactions will be required for use by all health plans, providers and clearinghouses that conduct business electronically by 1/1/2012. SDMC will reject claims in the 4010A1 format beginning on 1/1/2012.

The following are planned key dates for the implementation of X12 5010 SD/MC:                                                                     Back to Top

Planned Key Dates

 -- The 5010 SDMC Companion Guide has been temporarily removed while  undergoing maintenance--

Aug. 15, 2012
5010 Training
May 20, 2011 & June 9, 2011
System Design and Development June through August 2011
Internal Testing August and September 2011
Trading Partner 5010 Testing October 2011
Live Implementation- Compliance Deadline for HIPAA 5010 January 1, 2012

5010 Cut-Over Approach

On December 14, 2011, DMH released the 4010 to 5010 Cut-Over Approach to the Trading Partners. Cut-Over Resolution: December 7, 2011.pdf  


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Last modified on: 4/4/2017 11:44 AM