EDI Standards Development Pamela A. Grosze, Manager of Systems and Software Engineering, NDCHealth.
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Transcript of EDI Standards Development Pamela A. Grosze, Manager of Systems and Software Engineering, NDCHealth.
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EDI Standards DevelopmentEDI Standards Development
Pamela A. Grosze,
Manager of Systems and Software Engineering, NDCHealth
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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)
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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
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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
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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.
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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
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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
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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
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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
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ASC X12 ProductsASC X12 Products
X12 Standards
X12 Implementation Guides
Federal or state Regulations
HIPAA
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ProductsProducts
Transaction Sets, made up of– Segments– Data Elements– Code Values
Implementation Guides
X12
305
1
X12
501
0
X12
401
0
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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
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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
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Implementation GuidesImplementation Guides
Additional Code Sources are DefinedExamples and Test Cases Data DictionaryUse of Envelopes and Functional
Acknowledgements
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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
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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
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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
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Implementation Guide ExampleImplementation Guide Example
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Implementation Guide ExampleImplementation Guide Example
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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
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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)
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Change Example - IGChange Example - IG
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Change Example - IGChange Example - IG
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Change Example - StandardChange Example - Standard
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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
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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
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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
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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~
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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