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7030- Need for Change and Implications

The proposal for the next version of HIPAA EDI standards in the 5010 series is the hot topic in the healthcare industry. Healthcare industry being most data-intensive, the people associated with it have reasons to familiarize themselves with the new upgrade.

The new version would be called 7030 and accommodating the new version becomes important to healthcare suppliers.

EDI is used to submit healthcare claim billing information, encounter information, or both, except for retail pharmacy claims. Two critical factors influencing the need for payers and providers to acquaint themselves with the update and to implement it as soon as required are:

  • The industry is undergoing digitization
  • The EDI transactions are fundamental to healthcare business operations

For a majority of the healthcare industry, the 7030 is a replacement for the in-use 5010 standards covering all HIPAA related transactions between physicians, hospitals, payers, clearinghouse, pharmacies, and dentists.

Why do we need this change & what does it imply?

This would be a question that is troubling anyone who is in the healthcare industry and has heard about the new version. Before answering that, let’s get an idea of what exactly is HIPAA 7030.

HIPAA 7030 mandate is an enhancement of HIPAA 6020.

The objectives of HIPAA 7030

  1. To reduce the administrative burden of healthcare
  2. Ensuring that facilities, physicians, and payers utilize complete and consistent data electronically
  3. Analysis of healthcare information
  4. To meet the higher standard of requirements for eligibility transaction and claim transactions
  5. To ease the use of EDI

Significant changes in each of the EDI transactions will have major impacts on many business processes and systems.

Don’t be too hard on yourself if you still haven’t understood the transition to 7030. Let’s first understand that the transition of 7030 is not to make our lives miserable but the ever progressing industry demands a new set of standards to accommodate diverse business challenges and requirements. The new standard 7030 brings in more consistency across all transactions and supports the standards across the industry.

Impacts of HIPAA 7030

With the new changes, impacts are bound to happen. The 7030 update will mostly impact the operational and strategic business areas of all healthcare vendors who process EDI transactions.

The core areas to be impacted:

  • Subscriber Enrollment
  • Premium Billing
  • Patient Eligibility
  • Benefit Inquiry
  • Claim Transactions
  • Information Source

These areas cover more than 50% of healthcare business transactions and are the key areas for both Payers and Providers, as enrollment and claims bring revenue to them respectively.

So, why exactly do we need this?

With more than 3000 changes proposed in the new 7030 version, it is vital for Payers and Providers to assess the impact and address their existing policies, processes, and systems to ensure compliance. These changes range from simple changes like expanding the character length to more significant changes as sending and accepting new data fields and values. Analyzing and remediating each of these impacts and solutions from an operational and strategic process is a significant challenge.

Changes to be expected:

You might be wondering what the key changes aimed at with the new version are.

The implementation of 7030 presents substantial changes in the content of the data involved in outgoing and incoming transactions. Thus, this would require all the health plans to upgrade their business policies, processes, and systems for accommodating 7030 changes.

One should be very careful while handling the processes!

An inadequate remediation or small glitches in remediation can result in thousands of claims dropping to paper. This implies greater manual effort and hence increased costs as well as payment delays, incorrect enrollment and increase patient-provider dissatisfaction.

A closer evaluation of the standard indicates that this compliance is not just about transactions, codes, data elements, field length; it is also about tactful change management along with business and clinical processes re-engineering.

In the next part, we will be helping you understand how to take up this transition with the minimum downtime. We help you understand the process so that you can have success the very first time around.

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Thejesh Kumar C

Thejesh Kumar C

Thejesh has vast experience in claim benefit management, ANSI X12 transactions, HL7, Medicare & Medicaid solutions, Enrolment and other key areas. He is an avid sports lover and has played professional cricket at the junior level. He also loves to travel in his free time.
Thejesh Kumar C

Latest posts by Thejesh Kumar C (see all)

Thejesh Kumar C
Thejesh Kumar C

Thejesh has vast experience in claim benefit management, ANSI X12 transactions, HL7, Medicare & Medicaid solutions, Enrolment and other key areas. He is an avid sports lover and has played professional cricket at the junior level. He also loves to travel in his free time.

All stories by: Thejesh Kumar C