EDI Standards Development Pamela A. Grosze, Manager of Systems and Software Engineering, NDCHealth

EDI Standards Electronic Data Interchange –Files exchanged for many purposes – Healthcare, Banking, Purchasing, Transportation, etc. Standards important so each Trading Partner knows what the data format will be ( one to one versus many to many)

American National Standards Institute - ANSI Voluntary Organization Includes private and public sectors Approves standards developed by Accredited Standards Committees (ASC), e.g. ASC X12 Requires a consensus process Not government subsidized Represents the U.S. on all ISO committees

Data Interchange Standards Association (DISA) Not-for-profit organization Serves as secretariat for ASC X12 –Handles communication with ANSI, manages the standards database, publishing, ballots, other administrative matters X12 meets 3 times per year –February –June –October

ASC X12 Subcommittee The highest body under X12 Many subcommittees within X12 each with a different scope. They all begin with “X12” and end with an alphabetic suffix such as X12F (Finance), X12K (Purchasing), X12N (Insurance), etc.

X12 X12IX12JX12KX12LX12NX12MT&I X12HX12GX12FX12EX12AX12C TG1TG2TG3TG4TG7TG5TG8TG9 SP TG1 WG1WG2WG3WG4WG9WG5WG10WG12WG15

ASC X12 Task Group Most Subcommittees have one or more Task Groups Task Groups deal with specific segments of work related to the Subcommittee

X12N Task Groups TG1 TG2 TG4 TG5 TG7 TG9 TG3 Property and Casualty Health Care Implementation Guides Life & Annuity Reinsurance EDIFACT Business & Info. Modeling TG8 Architecture TG11 Education

TG2 - Health Care Workgroups WG1 WG2 WG3 WG4 WG5 WG12 WG15 Eligibility 270, 271, IHCEBI and IHCEBR Claims 837 Claim Payment 835, 269 Enrollment 834 Claim Status 276,277 Provider Information, 274 WG9 WG10 Patient Info. 275 HC Svs. Review 278 Interactive HC Claims IHCLME

ASC X12 Products X12 Standards X12 Implementation Guides Federal or state Regulations HIPAA

Products Transaction Sets, made up of –Segments –Data Elements –Code Values Implementation Guides X X X

An Implementation Guide Is: A document explaining the ASC X12 preferred implementation characteristics for a specific business process in great detail

Implementation Guides Define Business Cases and Scenarios Define Required, Situational and Not Used Segments and Elements –Required = Mandatory –Situational = Optional Situations for use will be defined in notes If you have the data, you should send it Define Which Codes Can Be Used

Implementation Guides Additional Code Sources are Defined Examples and Test Cases Data Dictionary Use of Envelopes and Functional Acknowledgements

Comments Provide additional information about the intended meaning or use of data element(s) within a specified data segment. –Comments are not part of the standard –Reflect intent of developers of the IG to eliminate interpretation

Workgroup Process Review of issues with determination of resolution Incorporation of overall changes in standards or verbiage Review of guide for completeness and accuracy Pushing guide through publication process, including submission, open forums, comment periods

IG Development Draft IGs will be made available for public review and open forums will be held to gain consensus prior to the approval process Publication Cycle is not yet stabilized, IGs published approx. every 2 years

Implementation Guide Example

Implementation / Standards Changes Issues submitted –Issues brought up at Trimester meetings –Submitted through HIPAA portal –Submitted during IG review process –Submitted to DSMO organization Issues reviewed –Reviewed by workgroup –Evaluated for change to IG or Standard

Implementation / Standards Changes IG changes can be added by workgroup Standards changes must be approved by workgroup(s), Task Group(s), Subcommittee(s), Architecture(s)

Change Example - IG

Change Example - Standard

Implementation Guide Publisher Washington Publishing Company (WPC) ( provides –Authors with administrative support –IG development software tool –Technical advice and IG editing –WPC manages the manufacturing and distribution process

HIPAA - Administrative Simplification Health Care industry wanted administrative simplification (one format, one guide for all!) HIPAA’s Purpose –Improve the efficiency and effectiveness of the health care system, by standardizing the electronic data interchange of certain administrative and financial transactions. –Protect the security and privacy of transmitted information. –Data Standardization. Changes no more often than every 12 months

HIPAA states that all trading partners will use: X12 Version 4010 and corresponding implemenation guides. (Pharmacy transactions are NCPDP v.5.1) n Premium payments - 811/820 n Enrollment and disenrollment n Eligibility - 270/271 n Referral Certification and Authorization n Claims / Encounters / COB n Claims status 276/277 n Health care payment and remittance advice EDI Standards

ISA*00* *00* *ZZ*NDC STD REMIT *ZZ* *020412*1506*U*00401* *0*P*>~ GS*HP*NDC STD REMIT*123456* *1506*1*X*004010X091~ ST*835*10001~ BPR*I* *C*CHK************ ~ TRN*1*12345* ~ N1*PR*INSURANCE ONE*XV* ~ N1*PE*PROVIDER ONE*FI*123456~ LX*130106~ TS3*123456*13* * *89.65*89.65***13.62**59.58****89.65*16.45~ CLP* *1*89.65*13.62*0*MA* *13*1~ NM1*QC*1*DOE*SALLY*J***HN*SJD11111~ MOA**30.07~ SVC*HC>93798*89.65*13.62*943~ CAS*PR*2*16.45~ CAS*OA*94*59.58~ CLP* *19*128.7*59.87*0*MA* *14*1~ NM1*QC*1*DOE*SALLY*J***HN*SJD11111~ NM1*TT*2*ACME INSURANCE*****PI* ~ MOA**59.87~ SVC*HC>80053*33*11.96*301~ CAS*CO*42*21.04~ SVC*HC>80061*38.5*13.96*301~ CAS*CO*42*24.54~ SVC*HC>84443*44*23.21*301~ CAS*CO*42*20.79~ PLB*123456* *BD*-2219*BD*-813~ SE*6225*10001~ GE*1*1~ IEA*1* ~

IMPORTANT WEB SITES HIPAA Portal – Quick Links, X12 Interpretationswww.x12.org