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Transaction Standards

Health Claims or Equivalent Encounter Information

Accredited Standards Committee (ASC) X12, Health Care Task Group

The main objective of ASC X12 is to develop standards to facilitate electronic interchange relating to such business transactions as order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions, and other data associated with the provision of products and services. The aim of ASC X12 is to structure standards so that computer programs can translate data to and from internal formats without extensive reprogramming. In this way, by using internally developed or commercially available software and private or public-access communication networks, ASC X12 believes that all sizes of firms and institutions using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties and expenses that could be incurred if each institution were to impose its own formats on every institution with which it does business. In ASC X12, the various subcommittees develop new standards that become recommendations for the full ASC X12 membership. The full ASC X12 membership must go through a consensus process before a proposed standard (or any change to a standard) is published as a Draft Standard for Trial Use. After a reasonable trial period, these standards are submitted to ANSI to start the process of consensus approval and registration.

ASC X12 has eleven Subcommittees including ASC X12N - Insurance. The ASC X12 subcommittees have maintained liaison with and obtained membership from a broad spectrum of businesses, government agencies, and institutions throughout the world. Communication is maintained with many organizations having experience in similar activities. A list of those participating in the development of the standards may be secured by contacting the Data Interchange Standards Association (DISA), Secretariat to ASC X12.

ANSI Accreditation: X12 was accredited as an ANSI accredited standards committee in 1979. Subsequent X12 procedure changes have required ANSI re-accreditation which was last granted in 1987.

The main objective of ASC X12 is to develop Electronic Data Interchange (EDI) standards to facilitate electronic business transactions (i.e. order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions). ASC X12 endeavors to structure standards in a manner that computer programs can translate data to and from internal formats without extensive reprogramming.

This strategy allows companies to maximize their resources required for internally developed or commercial software (recommended) and private or public-access communication networks. ASC X12 believes that all sizes of companies using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties incurred from each organization using its own formats to transact business. Within ASC X12, the various subcommittees are responsible for developing standards in their area of expertise. Once a subcommittee has developed a draft standard the full ASC X12 membership reviews and approves it according to the operating policies and procedures. All standards (new or changed) require the consensus approval of the full ASC X12 membership. The approved standard becomes a draft standard for trial use for a reasonable trial period. After the trial period the draft standards are submitted to ANSI to become an American National Standard (ANS).

ASC X12N Health Care Claim (837)

Contact For More Information: Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standard:

A) The objective of the Health Care Claim (837) is to support the administrative reimbursement processing as it relates to the submission of health care claims for both health care products and services.

B) This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

C)This transaction is used for administrative reimbursement for health care products and services for medical, hospital, dental, pharmaceutical, durable medical equipment claims as well as for workers compensation jurisdictional reporting.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has been developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all types of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard:

A) The Health Care Claim (837) is not a guideline.

B)The Health Care Claim (837) standard is fully implementable. The transaction set was approved as a Draft Standard for Trial Use (DSTU) in October of 1992 as Version 003030.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)This standard does not require an implementation guide. ASC X12 has published four Type II Tutorial reports or tutorials for version 003041 in October of 1994, version 003050 in October 1995, version 003051 in February 1996, and version 003060 in April of 1996. To facilitate consistent implementation across the health care industry, the X12 Insurance Subcommittee is currently in the process of completing five implementation guides for version 003070 encompassing medical, hospital, dental, pharmaceutical claims, and workers compensation jurisdictional reporting with an anticipated publication date of June 1997.

E)There will be only one implementation guide per claim type for each version of the standards the X12 Health Care Task Group selects in accordance with the industry.

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance:

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)All Medicare carriers and intermediaries have implemented ASC X12 standards for claims. Many other payers have followed HCFA's lead and implemented the standard as well.

C)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards because costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity:

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards:

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

A) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

B)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

C)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

D)The current use of proprietary formats such as the National Standard Format (NSF) and the costs of maintaining these formats far outweigh the costs associated with implementing a single set of the health care industry standards from ASC X12.

TABLE OF CONTENTS