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EDI Standards Development

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.

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EDI Standards Development

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

  2. 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)

  3. 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

  4. 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

  5. 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.

  6. WG1 WG2 WG3 WG4 WG5 WG9 WG10 WG12 WG15 X12 X12A X12C X12E X12F X12G X12H X12I X12J X12K X12L X12M X12N T&I TG1 TG2 TG3 TG4 TG5 TG7 TG8 TG9 SP TG1

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

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

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

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

  11. Products • Transaction Sets, made up of • Segments • Data Elements • Code Values • Implementation Guides X12 4010 X12 3051 X12 5010

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

  13. 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

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

  15. 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

  16. 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

  17. 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

  18. Implementation Guide Example

  19. Implementation Guide Example

  20. 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

  21. 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)

  22. Change Example - IG

  23. Change Example - IG

  24. Change Example - Standard

  25. Implementation 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

  26. 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

  27. EDIStandards 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

  28. 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~

  29. IMPORTANT WEB SITES • http://www.disa.org • http://www.x12.org/ • http:// www.wedi.org • http://aspe.hhs.gov/admnsimp/ • http://www.wpc-edi.com • HIPAA Portal – www.x12.org, Quick Links, X12 Interpretations

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