5010 & D.0 Transaction Standards

doctor using laptop

What are 5010 HIPAA transaction standards?

The 5010 HIPAA transaction standards are a new set of standards that regulate the electronic transmission of specific health care transactions. These include eligibility, claim status, referrals, claims and electronic remittance.

We currently conduct electronic provider transactions exclusively in the HIPAA-mandated version 5010. We plan to meet all applicable timeframes required to adopt the ICD-10 code set upgrades, as established by Health and Human Services. We are actively engaged in the planning and execution stages for all aspects of the program.

See updates and changes to 5010 HIPAA transaction standards

What is the NCPDP D.0 billing transaction?

The National Council for Prescription Drug Programs (NCPDP) maintains requirements regarding the standard way that pharmacy claims must be transmitted.

Telecommunications Standard Version D.0 is an updated version of the HIPAA standard for pharmacy claims transactions. It is an online, real-time request from the pharmacy to the health plan and a response from the health plan to the pharmacy.

Who is required to submit in NCPDP D.0 format?

Any covered entity using electronic transmission of pharmacy information is required to submit in the NCPDP D.0 format. This includes:

  1. Health plans
  2. Health care clearinghouses
  3. Health care providers who transmit health information in electronic form in connection with a transaction covered by this subchapter, for example, HIPAA Administrative Simplification transaction standards

Aetna 2014 Payer Sheets - Revised April 2014 (detailed technical specifications):

If you have questions about specific fields in any of the sheets below, consult with your chain headquarters or software vendor.

Claim Billing B1 Commercial Payer Sheet
Claim Billing B1 Medicare Payer Sheet
Claim Billing B1 COB Payer Sheet
Claim Reversal B2 Payer Sheet

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