Copyright Red Raven Productions. Designation X12 Founded in 1979 August of 2000 Transaction Standards

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1 PRESENTATION HIPAA Privacy & Security X12 ICD GEM It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change. - Charles Darwin HIPAA X12N - ICD CH1: HIPAA Overview Brief History of HIPAA HIPAA Privacy & Security ICD-GEM.com CH2: X12N Transactions Overview Key EDI Transactions : Subcommitees, Task Groups, Work Groups X12N Overview CH3: ICD GEM Overview CH2: Transactions Matrix Compliance Timelines CH4: Boothill Death Registry Manager CH5: ICD GEM Manager CH6: ICD GEM SuperBill

2 They all begin with X12 and end with an alphabetic suffix Health care business transactions include: patient scheduling registration clinical reporting and billing Health care business applications are involved in the storage and movement of medical records and transactions. Health care transactions are quite varied. Regulations were published naming specific electronic transactions and code sets covered under HIPAA. The transactions were developed by the X12 (aka:asc X12), which is a standards Designation development organization. X12 Transaction All of the transactions adopted by this rule are from the (ASC) XI2N except for the standards for retail pharmacy transactions. Retail pharmacy transactions are from the Council for Prescription Drug Programs (NCPDP) Scope: Transaction standards apply only when data is transmitted electronically (EDI) between health care providers and health plans as part of a standard transaction. Transaction Compliance: All covered entities that choose to transmit any transactions in electronic form had to comply with the final rule by October 16, Transaction Releases

3 Every new release contains new version number. Version number examples: 4010, 4020, 4030, 5010, 5030, etc. Major releases start with new first number and 5010 Designation are major releases. X12 major releases and 5030 are minor releases. Transaction Releases Minor releases contain minor changes or improvements over Key EDI Transactions 837: Medical Claims Professional, Institutional, and Dental 820: Payroll Deducted, Other Group Premium Payment for Insurance Products 834: Benefits Enrollment - Maintenance 835: Electronic Remittances 270/271: Eligibility; Inquiry/Response 276/277: Claim Status; Inquiry/Response 278: Health Services Review; Request/Reply X12I Subcommittee X12A X12C X12F X12G X12J X12K X12 X12M X12N X12X X12A X12C X12F X12G X12I X12J X12K X12M X12N X12X Subcommittee Education Communications & Controls Finance Government Transportation Technical Assessment Purchasing Supply Chain Insurance Steering X12I Task Groups X12A X12C X12F X12G X12J X12K X12 X12M X12N X12X TG1 TG2 TG3 TG4 TG5 TG7 TG8 TG9 TG11 TG1 TG2 TG3 TG4 TG5 TG7 TG8 TG9 TG11 Task Groups Property and Casualty Health Care Business & Info. Modeling Implementation Guides Life & Annuity Reinsurance Architecture EDIFACT Education

4 X12I Work Groups X12A X12C X12F X12G X12J X12K X12M X12N X12X TG1 TG2 TG3 TG4 TG5 TG7 TG8 TG9 TG11 WG1 WG2 WG3 WG4 X12 WG5 WG9 WG10 WG15 WG 12/20/21 Work Groups WG1 Health Care Eligibility (270, 271, ICHEBI, ICHEBR) WG2 Health Care Claims (837) WG3 Claim Payments (835, 269) WG4 Enrollments And Premium Payments (820, 834) WG5 Claims Status (276, 277) WG9 Patient Information (275) WG10 Health Care Services Review (278) WG15 Provider Information (274) WG12 Interactive Health Care Claims (IHCLME) WG20 Insurance Transaction Acknowledgment WG21 HIPAA Implementation/Coordination Transactions Matrix DESCRIPTION Transactions Matrix DESCRIPTION Eligibility, Coverage or Benefit: Inquiry X X First Report of Injury/Hospitalization X X2 271 Eligibility, Coverage or Benefit: Information X X Provider Information X X2 276 Claim Status: Request X X Health Claims Attachments X X2 277 Claim Status: Notification X X Consolidated Service Invoice X X2 278 Services Review: Request for Review 278 Services Review: Response 820 Payment Order/ Remittance Advice 834 Benefit Enrollment and Maintenance 835 Claim Payment/Advice 837 Claim: Institutional 837 Claim: Dental 837 Claim: Professional X X X X X X X X X X X X X X X X222 These are not HIPAA covered transactions Transactions Matrix DESCRIPTION Eligibility, Coverage or Benefit: Inquiry 271 Eligibility, Coverage or Benefit: Information 276 Claim Status: Request 277 Claim Status: Notification 278 Services Review: Request for Review 278 Services Review: Response 820 Payment Order/ Remittance Advice 834 Benefit Enrollment and Maintenance 835 Claim Payment/Advice 837 Claim: Institutional 837 Claim: Dental 837 Claim: Professional X X X X X X X X X X X X222

5 Standard format data is a text file separated by: segment, element and sub-element delimiters Each segment does not need to be displayed on the separate line In most cases, segments end with a ~ (tilde) Called a segment separator or delimiter Each segment starts with 2-3 letter code that identifies it: Example: ISA, GS, ST, BHT are all segment identifiers Each segment contains elements separated by element separators In most examples it s an asterisk or star (*) Separators can be printable or non-printable They can be other characters like; greater than or less than signs (< >) pipe sign ( ) also non-printable characters Most translators detect separators for incoming EDI X12 files The segments are ISA, GS, ST, SE, GE, IEA. The segments are ISA, GS, ST, SE, GE, IEA. The transmission of data proceeds according to very strict format rules to ensure the integrity and maintain the efficiency of the interchange. Each business grouping of data is called a transaction set. Each transaction set contains groups of logically related data in units called segments. A transaction set contains multiple segments. The sequence of the elements within one segment is specified by the ASC X12 standard as well as the sequence of segments in the transaction set. One or more functional groups are prefaced by an interchange header and followed by an interchange trailer. Some segments form an EDI X12 Envelope They are common to all EDI X12 files and message types This set contains important information about trading partners: e.g., Sender Id, Receiver Id, etc. It also contains interchange, transaction group and transaction control numbers, counts, transmission dates and times, and more

6 Some segments form an EDI X12 Envelope Enveloping segments work in pairs Communications Envelope Communications Transport Protocol Communications Transport Trailer X12N Control Segments & Envelopes Interchange (ISA/IEA) Segments Functional Group (GS/GE) Segments Transaction Set Header (ST) Segments Interchange (ISA/IEA) Segments Min Max Element Element Name Length Length ISA01 Authorization Information Qualifier ISA02 Authorization Information ISA03 Security Information Qualifier ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID ISA07 Interchange ID Qualifier ISA08 Interchange Receiver ID X12N Control Segments & Envelopes Interchange (ISA/IEA) Segments Functional Group (GS/GE) Segments Transaction Set Header (ST) Segments ISA09 ISA10 ISA11 ISA12 ISA13 ISA14 ISA15 ISA16 Interchange Date Interchange Time Interchange Control Identifier Interchange Control Version Number Interchange Control Number Acknowledgment Requested Usage Indicator Component Element Separator Functional Group (GS/GE) Segments Min Max Element Element Name Length Length GS01 Functional Identifier Code 2 02 GS02 Application Sender's Code 2 15 GS03 Application Receiver's Code 2 15 GS04 Date 8 08 GS05 Time 4 08 X12N Control Segments & Envelopes Interchange (ISA/IEA) Segments Functional Group (GS/GE) Segments Transaction Set Header (ST) Segments GS06 Group Control Number 1 09 GS07 Responsible Agency Code 1 02 GS08 Version/Release/Industry Identifier Code 1 12

7 Transaction Set Header (ST) Segments Min Max Element Element Name Length Length ST01 ST02 Transaction Set Identifier Code 3 3 Transaction Set Control Number 4 9 Some segments repeat more than once. In most cases, they have different qualifiers inside in order to be identified. X12N Control Segments & Envelopes Control Numbers Transaction Numbers EDI Loops Properties Compliance Timelines Fully compliant Copyright Center for Medicare and Medicaid Services (CMS) ASC X A1 to ASC X NCPDP 5.1 to NCPDP D.0 Description Final rule was published Effective Date of the regulation Level I Compliance Level II Compliance (extended) Deadlines 16-Jan Mar Dec Jun Jul-2012 HHS permits dual use of existing standards (4010A1 and 5.1) and the new standards (5010 and D.0) from the March 17th, 2009, effective date until the June 30th, 2012 compliance date to facilitate testing subject to trading partner agreement. Compliance Timelines Description Level I Level II Fully compliant Copyright The CMS Medicare Fee-for-Service Schedule Deadlines 1-Apr-10 Thru 31-Dec-10 1-Jan-11 Thru 31-Dec Jun-12 CMS has prepared a comparison of the currentx12 HIPAA EDI standards (Version 4010/4010A1) with Version 5010 and the NCPDP EDI standards Version 5.1 to D.0. The 4010A1 Implementation Guides and the 5010 Technical Report 3 (TR3) documents served as reference materials during the preparation of the comparison Excel spreadsheets. QUIZ :10 :09 :08 :07 :06 :05 :04 :03 :02 :01 :00 QUIZ Which transaction is used to enroll, update, or dis-enroll employees and dependents in a health plan? A.834 B.820 C.837 D.270 E. 277 Which transaction is used to enroll, update, or dis-enroll employees and dependents in a health plan? A.834 Benefit Enrollment and Maintenance B.820 Payment Order/ Remittance Advice C.837 Claim: Institutional/Dental/Professional D.270 Eligibility, Coverage or Benefit: Inquiry E. 277 Claim Status: Notification

8 :00 :01 :02 :03 :04 :05 :06 :07 :08 :09 :10 QUIZ Of the following which is NOT a HIPAA covered transaction? 1) Claims 2) First report of hospitalization 3) Coordination of benefits 4) Eligibility inquiry and response QUIZ Of the following which is NOT a HIPAA covered transaction? 1) Claims (837) 2) First report of hospitalization (148) 3) Coordination of benefits 4) Eligibility inquiry and response (270,271) 8 standard transactions were named in the rule. If an organization conducts any one or more of those transactions in electronic media they must comply with HIPAA. REFERENCES Dental Association Medical Association ANSI (ASC) X12 Centers for Medicare and Medicaid Services (CMS) Dept. of Health & Human Services (HHS) Health Level Seven (HL7) on Vital and Health Statistics (NCVHS) Council for Prescription Drug Programs (NCPDP) Uniform Billing (NUBC) Uniform Claim (NUCC) Washington Publishing Company (WPC) Workgroup for Electronic Data Interchange (WEDI) Thomas Edison Thomas Dwyer, CHPSP CREDITS Author, Director, Editor, Presenter Sandra Remis, M.A Editor Dr. Ariel Schrodt, PHD Video Director Dr. John D. Butterworth, PHD HIPAA Architect Red Raven Moqueet A. Syed, P.E. HIPAA Instructor Productions ECMC.org CANTV.org Copyright Red Raven Productions Tom Dwyer ICD-GEM.com