EDI Standards DevelopmentEDI Standards Development

Pamela A. Grosze,

Manager of Systems and Software Engineering, NDCHealth

EDI StandardsEDI 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 American National Standards Institute - ANSIInstitute - ANSIVoluntary Organization Includes private and public sectorsApproves standards developed by

Accredited Standards Committees (ASC), e.g. ASC X12

Requires a consensus processNot government subsidizedRepresents the U.S. on all ISO committees

Data Interchange Standards Data Interchange Standards Association (DISA)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 SubcommitteeASC X12 Subcommittee

The highest body under X12Many 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

X12I X12J X12K X12L X12NX12M T&I

X12HX12GX12FX12EX12A X12C

TG1 TG2 TG3 TG4 TG7TG5 TG8 TG9SP

TG1

WG1 WG2 WG3 WG4 WG9WG5 WG10 WG12WG15

ASC X12 Task GroupASC 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 GroupsX12N Task Groups

TG1

TG2

TG4

TG5

TG7

TG9

TG3

Property and Casualty

Health Care

ImplementationGuidesLife & Annuity

Reinsurance

EDIFACT

Business & Info. Modeling

TG8 Architecture

TG11 Education

TG2 - Health Care WorkgroupsTG2 - Health Care Workgroups

WG1

WG2

WG3

WG4

WG5

WG12

WG15

Eligibility 270, 271, IHCEBI and IHCEBR

Claims 837

Claim Payment 835, 269

Enrollment 834Claim Status 276,277

Provider Information,

274

WG9

WG10

Patient Info. 275

HC Svs. Review 278

Interactive HC ClaimsIHCLME

ASC X12 ProductsASC X12 Products

X12 Standards

X12 Implementation Guides

Federal or state Regulations

HIPAA

ProductsProducts

Transaction Sets, made up of– Segments– Data Elements– Code Values

Implementation Guides

X12

305

1

X12

501

0

X12

401

0

An Implementation Guide Is:An Implementation Guide Is:

A document explaining the ASC X12 preferred implementation characteristics for a specific business process in great detail

Implementation GuidesImplementation Guides

Define Business Cases and ScenariosDefine 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 GuidesImplementation Guides

Additional Code Sources are DefinedExamples and Test Cases Data DictionaryUse of Envelopes and Functional

Acknowledgements

CommentsComments

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 ProcessWorkgroup 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 DevelopmentIG 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 ExampleImplementation Guide Example

Implementation Guide ExampleImplementation Guide Example

Implementation / Standards ChangesImplementation / 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 ChangesImplementation / 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 - IGChange Example - IG

Change Example - IGChange Example - IG

Change Example - StandardChange Example - Standard

Implementation Guide PublisherImplementation Guide Publisher

Washington Publishing Company (WPC) (www.wpc-edi.com) provides – Authors with administrative support– IG development software tool– Technical advice and IG editing– WPC manages the manufacturing and

distribution process

HIPAA - Administrative SimplificationHIPAA - 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)

Premium payments - 811/820

Enrollment and disenrollment - 834

Eligibility - 270/271 Referral Certification

and Authorization - 278

Claims / Encounters / COB - 837

Claims status 276/277 Health care payment and

remittance advice - 835

EDIEDI StandardsStandards

ISA*00* *00* *ZZ*NDC STD REMIT *ZZ*123456 *020412*1506*U*00401*000000001*0*P*>~GS*HP*NDC STD REMIT*123456*20020412*1506*1*X*004010X091~ST*835*10001~BPR*I*92854.99*C*CHK************20020412~TRN*1*12345*1512345678~N1*PR*INSURANCE ONE*XV*88888888~N1*PE*PROVIDER ONE*FI*123456~LX*130106~TS3*123456*13*20010630*20010630*89.65*89.65***13.62**59.58****89.65*16.45~CLP*7722337*1*89.65*13.62*0*MA*119932404007801*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*7722337*19*128.7*59.87*0*MA*119932404007801*14*1~NM1*QC*1*DOE*SALLY*J***HN*SJD11111~NM1*TT*2*ACME INSURANCE*****PI*123456789~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*20020630*BD*-2219*BD*-813~SE*6225*10001~GE*1*1~IEA*1*000000001~

IMPORTANT WEB SITESIMPORTANT WEB SITES

http://www.disa.orghttp://www.x12.org/http:// www.wedi.orghttp://aspe.hhs.gov/admnsimp/http://www.wpc-edi.comHIPAA Portal – www.x12.org, Quick

Links, X12 Interpretations