the next version of the asc x12 implementation guides: what’s in
TRANSCRIPT
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
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
● Enter a brief description of the requested change in the Title field
How to submit a Change Request
● Enter a detailed description of the business rationale for the requested
change in the Business Reason field
How to submit a Change Request
● 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
How to submit a Change Request
● Check all affected ASC X12 work products
● Or check the unspecified box at the bottom of the screen, and click the
Create button
How to submit a Change Request
Am I done?
No, you have only created your request you have not submitted it yet.
How to submit a Change Request
● 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.
How to submit a Change Request
● Review the information entered for the request to ensure it is complete.
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