The Next Version of the ASC X12 Implementation Guides: Whatâ€™s In

The Next Version of the ASC X12

Implementation Guides: What’s In

and What’s Out

Presenters

Nancy Spector, AMA

Margaret Weiker, The Weiker Group

Kelly Butler, Emdeon

Penny Probst, Highmark

WEDI: Who are We?

● The Workgroup for Electronic Data Interchange (WEDI) is a leading authority on the use

of Health IT to improve healthcare information exchange in order to enhance the quality

of care, improve efficiency and to reduce costs of our nation’s healthcare system.

● WEDI is an industry organization named in the 1996 HIPAA Law as advisor to the

Secretary of Health and Human Services.

● WEDI is a consensus based organization when bringing forward policy

recommendations that have been vetted by its membership from all key stakeholders

● WEDI’s membership includes a broad coalition of organizations, including: hospitals,

providers, health plans, vendors, government agencies, consumers, not-for-profit

organizations and standards bodies.

● WEDI is seen across the industry as a neutral facilitator that involves representation

from providers, plans, clearinghouses, vendors, government, SDOs, ORAEs, DCCs and

others.

● WEDI’s workgroups have the depth in SME participation to discuss policy, business and

implementation issues of each transaction based on regulations, standards and

operating rules (e.g. the PAGs).

● WEDI is well known for hosting multiple Industry Forums on key healthcare initiatives

and has held hearings on HIPAA implementation progress, barriers, and best practices.

Who is ASC X12

• Chartered and accredited by the American National Standards

Institute (ANSI) more than 30 years ago

• The Accredited Standards Committee (ASC X12) develops and

maintains electronic data interchange (EDI) standards, technical

reports, and XML schemas which drive business processes globally

• ASC X12 membership includes technologists and business process

experts, encompassing many industries

• ASC X12 develops and publishes the HIPAA mandated technical

reports (TR3s) for 9 transactions - commonly called Implementation

Guides

– Current mandated version is 5010

– Visit www.x12.org for more information

http://www.x12.org/

ASC X12 – Benefits of Current Change Request Process

● Open – anyone can submit a request

● Public – comments and dispositions are posted

● Timing – consistent and well documented

● Consensus driven

● Multiple entry points – accessibility

● Transparent and documented

● Proven

– Continue to evaluate and improve

● It Works

– Over 500 change requests have been submitted between

versions

How to submit a Change Request

Go to http://www.x12.org/

● Click on TR3 Change Request Submission


Go to http://changerequest.x12.org/

● Click on Register


● Complete the Registration Form


● Click on Create Request


● Enter a brief description of the requested change in the Title field


● Enter a detailed description of the business rationale for the requested

change in the Business Reason field


● Enter the recommended solution to the change request or a detailed

description of the issue that prompted the request for the change in the

Description field


● Check all affected ASC X12 work products

● Or check the unspecified box at the bottom of the screen, and click the

Create button


Am I done?

No, you have only created your request you have not submitted it yet.


● Click on View Requests


● Once you are in View Requests, you can edit your request or you can

submit your request.

● If you click on Edit, you will be able to modify any field on your change

request prior to submission.

● Once you are sure your request is complete, hit Submit.


● Review the information entered for the request to ensure it is complete.


● Scroll to the bottom of the page and click on Submit to Committee.


You have now successfully submitted your change request.

270/271 Eligibility and Benefit Inquiry and Response

Changes

● Added Cascading Logic for Member Search Options

● Added new General and Component level Service Type Codes for inquiries

● Changed the Service Type Code list to an external code list

● Added a requirement for Information Sources to support all Service Type

Codes

● Added a requirement for Information Sources to return patient financial

liability

● Increased the number of repeats for the Place of Treatment (III) segment

276/277 Health Care Claim Status Request and Response

Changes

● Modified entity codes to include 837 specific entities and standardized them across the 277

implementation guides

● Made changes to enhance the re-association for the 276/277

● Removed Provider-level status reporting (2200C STC)

● Replaced the generic Service Provider qualifier with specific Billing and Rendering Provider

qualifiers

● Added the Claim Received Date Segment to the claim level response

● Added Property and Casualty REF segment at the claim level of both the request and

response

● Added clarifying verbiage to claim level Service Date and changed usage of the date

● Created the ability to report service line payment details (STC)

● Modified the Service Line situational rules to clarify usage

● Added the Service Line segment (TOO) to the request and response

278 Health Care Services Review – Request for Review and Response

Changes

● Added Drug Authorization Segment to allow for the request of Drug

Authorizations for Prescriptions

● Added Tooth Status Segment to support dental industry requests

● Added Member Reference Qualifiers to accommodate Workmen's

Compensation and Property and Casualty

● Added new Diagnosis Code Qualifier to support NCPDP Medication Therapy

Management

● Removed Qualifiers for Provider Primary Identifiers to support the use of the

NPI

820 Premium Payment

Changes

● Added language to the Front Matter to clarify the intended use of the 820

● Added the INS, NM1,REF and DTP segments to loop 2000B to report

member data submitted on the 834

● Modified rules and data element usage to align with the 835 transaction

834 Benefit Enrollment and Maintenance

Changes

● Added the 2500 loop to accommodate Tax Advantage Account information

● Added explanatory language about the relationship of the 834 data to the

820 data

● Removed Qualifiers for Provider Primary Identifiers to support the use of the

NPI

835 Health Care Claim Payment/Advice

Changes

● Revised the Overpayment Recovery Front Matter section 1.10.2.17

● Removed the CAS segment and added the RAS segment

● Added the TOO segment

● Added Workers’ Compensation/Auto web site and Accident and Clean Claim

Dates

● Added Remittance Delivery Method

● Added the Source of Payment Typology element to the CLP segment

● Changed the PLB adjustment codes to an external code list

● Changed the usage of the Payer business and technical contact numbers

from situational to required

● Added indicators for type of claim and mode of delivery

837 Health Care Claim

Changes

● Added the Original Claim Creation Date

● Relaxed the 9 digit ZIP code requirement

● Changed CLM07 to Medicare Assignment Code

● Added CLM16 back into the Professional/Dental Transactions

● Changed the name and length of the CLM01

● Changed the SBR01 COB linkage

● Removed the Supervising Provider Primary Identifier REF Segment

● Removed the CAS segment and added the RAS segment

● Added modifiers

● Increased the number of Diagnosis Code Pointers from 4 to 12

Why Participate in ASC X12 Now

• Proactively shape the most widely used EDI

standards in a consensus-based environment

• Obtain early access to implementation guides and

modifications

• Networking and visibility

• Collaboration

Participation in WEDI

• Why participate?

• Be part of multi-stakeholder discussions and

development of solutions for business issues and

needs for administrative transactions

• How to participate?

• Become a member of WEDI

• Sign up for workgroup and subworkgroup listservs

• WEDI resources – available at www.wedi.org

• White papers

• Webinars

• Conferences and forums

http://www.wedi.org/

Questions?

Documents

The Next Version of the ASC X12 Implementation Guides: Whatâ€™s In