Project Overview - PowerPoint 6

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					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.
   Standards important so each Trading
    Partner knows what the data format
    will be ( one to one versus many to
    many)
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
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
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.
                             X12

        X12A    X12C    X12E       X12F     X12G    X12H

      X12I    X12J   X12K    X12L     X12M     X12N    T&I

                                                            SP
TG1     TG2    TG3     TG4   TG5      TG7     TG8    TG9
                                                           TG1

WG1 WG2 WG3 WG4 WG5 WG9 WG10 WG12 WG15
ASC 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 Groups
TG1 Property and
    Casualty           TG8 Architecture
TG2 Health Care
                       TG9 EDIFACT
TG3 Business & Info.
    Modeling
                       TG11 Education
    Implementation
TG4
    Guides
TG5 Life & Annuity

TG7 Reinsurance
  TG2 - Health Care Workgroups
WG1   Eligibility 270, 271, IHCEBI and IHCEBR

      Claims 837              WG9 Patient Info. 275
WG2

      Claim Payment 835,      WG10 HC Svs. Review 278
WG3
      269
      Enrollment 834          WG12 Interactive HC Claims
WG4                                IHCLME

WG5   Claim Status 276,277    WG15 Provider Information,
                                   274
ASC X12 Products

               HIPAA

            Federal or state
            Regulations

         X12 Implementation
         Guides


          X12 Standards
Products
   Transaction Sets, made up of
    – Segments
    – Data Elements
    – Code Values
   Implementation Guides




                                       X12 5010
                            X12 4010
                            X12 3051
An Implementation Guide Is:
   A document explaining the ASC X12
    preferred implementation
    characteristics for a specific
    business process in great detail
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
Implementation Guides
 Additional Code Sources are Defined
 Examples and Test Cases
 Data Dictionary
 Use of Envelopes and Functional
  Acknowledgements
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
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
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
Implementation Guide Example
Implementation Guide Example
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
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)
Change Example - IG
Change Example - IG
Change Example - Standard
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
    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
 EDI Standards
HIPAA states that all trading partners will use: X12
  Version 4010 and corresponding implemenation
  guides.
  (Pharmacy transactions are NCPDP v.5.1)
  Premium payments -           Claims / Encounters / COB
   811/820                       - 837
  Enrollment and               Claims status 276/277
   disenrollment - 834          Health care payment and
  Eligibility - 270/271         remittance advice - 835
  Referral Certification
   and Authorization - 278
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 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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posted:8/8/2012
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