L&I Readiness for ICD-10 & 5010

HIPAA 5010 transaction standards

The department has updated its systems and is HIPAA compliant with the Electronic Data Interchange (EDI) standards for electronic Health Care transactions. L&I’s system supports the following for 5010 transactions effective January 1, 2012:

  • Submissions
    • Health Care Claim: Professional 837 (005010X222A1)
    • Health Care Claim: Institutional 837 (005010X223A2)
  • Responses
    • Interchange Acknowledgment TA1
    • Implementation Acknowledgment 999 (005010X230A1)
    • Application Reporting for Insurance 824 (004010X161)
  • Notices
    • Health Care Claim Payment/Advice 835 (005010X221A1)
    • Health Care Claim Notification 277 (005010X214A1)
  • Pharmacy prescription billing
    • NCPDP version D.0 Pharmacy prescription billing
    • Health Care Claim Payment/Advice 835 (005010X221A1)

One of the key components of the EDI 5010 format for Professional and Institutional 837 transactions is support of ICD-10-CM codification.

The implementation of 5010 is a prerequisite for implementing ICD-10.

Effective April 1, 2014, the department will require all trading partners who upload files to submit files in the EDI 5010 837 format.

This requirement affects trading partners currently submitting in the EDI 4010 837 format and the HCFA Proprietary format.

If you currently submit in either of these formats and want to continue to upload billing files after April 1, 2014, you are required to convert your file submission to the EDI 5010 837 format.

The reason for this change is the EDI 4010 837 format and HCFA Proprietary format transactions do not support ICD-10.

What you need to know to continue billing electronically

Trading partners will need to review and update their systems accordingly. Please review our HIPAA 5010 Companion Guide for information and details in billing 5010 transactions. This guide details the format structure and provides information on billing electronically using PEB.

If you:

  • Submit in the 4010 837 format and are using vendor software, contact your vendor and ask about upgrading your software to the 5010 837 format.
  • Submit in the HCFA Proprietary format you are probably using an in-house custom written billing system. You will need to contact your IT or Technical support personnel for updating to 5010.

5010 Testing & Implementation Schedule as of 09/19/2013

Trading partners may perform external end-to-end testing with the department to include claim submission, claim adjudication processing, and claim acknowledgment and notification. The department won’t be able to accommodate testing of electronic remittance advices.

(Testing Process Flow)

Provider --> Clearinghouse --> L&I --> Clearinghouse --> Provider

Provider --> L&I --> Provider

  • The department has completed 5010 testing with its clearinghouse trading partners.
  • Trading partners converting from 4010 and HCFA formats are required to successfully complete testing of 5010 837 file submissions and transaction processing prior to authorization for production submissions.
  • January 1, 2012 – 5010 compliant with trading partners.
  • January 1, 2012 to April 1, 2014 – ongoing testing for trading partners converting from 4010 837 or HCFA Proprietary format to 5010 837 format.
  • April 1, 2014 – compliance date for all trading partners to be 5010 compliant with L&I.

If you have questions regarding 5010 or ICD-10, or want to schedule testing, contact the:

Electronic Billing Unit
Email: ebulni@lni.wa.gov
Phone: 360-902-6511

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