Transaction Standards

Health Claims or Equivalent Encounter Information

Accredited Standards Committee (ASC) X12, Health Care Task Group

The main objective of ASC X12 is to develop standards to facilitate electronic interchange relating to such business transactions as order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions, and other data associated with the provision of products and services. The aim of ASC X12 is to structure standards so that computer programs can translate data to and from internal formats without extensive reprogramming. In this way, by using internally developed or commercially available software and private or public-access communication networks, ASC X12 believes that all sizes of firms and institutions using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties and expenses that could be incurred if each institution were to impose its own formats on every institution with which it does business. In ASC X12, the various subcommittees develop new standards that become recommendations for the full ASC X12 membership. The full ASC X12 membership must go through a consensus process before a proposed standard (or any change to a standard) is published as a Draft Standard for Trial Use. After a reasonable trial period, these standards are submitted to ANSI to start the process of consensus approval and registration.

ASC X12 has eleven Subcommittees including ASC X12N - Insurance. The ASC X12 subcommittees have maintained liaison with and obtained membership from a broad spectrum of businesses, government agencies, and institutions throughout the world. Communication is maintained with many organizations having experience in similar activities. A list of those participating in the development of the standards may be secured by contacting the Data Interchange Standards Association (DISA), Secretariat to ASC X12.

ANSI Accreditation: X12 was accredited as an ANSI accredited standards committee in 1979. Subsequent X12 procedure changes have required ANSI re-accreditation which was last granted in 1987.

The main objective of ASC X12 is to develop Electronic Data Interchange (EDI) standards to facilitate electronic business transactions (i.e. order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions). ASC X12 endeavors to structure standards in a manner that computer programs can translate data to and from internal formats without extensive reprogramming.

This strategy allows companies to maximize their resources required for internally developed or commercial software (recommended) and private or public-access communication networks. ASC X12 believes that all sizes of companies using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties incurred from each organization using its own formats to transact business. Within ASC X12, the various subcommittees are responsible for developing standards in their area of expertise. Once a subcommittee has developed a draft standard the full ASC X12 membership reviews and approves it according to the operating policies and procedures. All standards (new or changed) require the consensus approval of the full ASC X12 membership. The approved standard becomes a draft standard for trial use for a reasonable trial period. After the trial period the draft standards are submitted to ANSI to become an American National Standard (ANS).

ASC X12N Health Care Claim (837)

Contact For More Information: Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standard:

A) The objective of the Health Care Claim (837) is to support the administrative reimbursement processing as it relates to the submission of health care claims for both health care products and services.

B) This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

C)This transaction is used for administrative reimbursement for health care products and services for medical, hospital, dental, pharmaceutical, durable medical equipment claims as well as for workers compensation jurisdictional reporting.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has been developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all types of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard:

A) The Health Care Claim (837) is not a guideline.

B)The Health Care Claim (837) standard is fully implementable. The transaction set was approved as a Draft Standard for Trial Use (DSTU) in October of 1992 as Version 003030.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)This standard does not require an implementation guide. ASC X12 has published four Type II Tutorial reports or tutorials for version 003041 in October of 1994, version 003050 in October 1995, version 003051 in February 1996, and version 003060 in April of 1996. To facilitate consistent implementation across the health care industry, the X12 Insurance Subcommittee is currently in the process of completing five implementation guides for version 003070 encompassing medical, hospital, dental, pharmaceutical claims, and workers compensation jurisdictional reporting with an anticipated publication date of June 1997.

E)There will be only one implementation guide per claim type for each version of the standards the X12 Health Care Task Group selects in accordance with the industry.

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance:

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)All Medicare carriers and intermediaries have implemented ASC X12 standards for claims. Many other payers have followed HCFA's lead and implemented the standard as well.

C)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards because costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity:

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards:

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

A) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

B)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

C)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

D)The current use of proprietary formats such as the National Standard Format (NSF) and the costs of maintaining these formats far outweigh the costs associated with implementing a single set of the health care industry standards from ASC X12.

ASC X12N Interactive Healthcare Claim/Encounter (IHCLME)

Contact For More Information: Data Interchange Standards Association (DISA)

703-548-7005.

Description of Standard:

A) The objective of the Interactive Healthcare Claim/Encounter (IHCLME) is to support the administrative reimbursement processing as it relates to the submission of health care claims for both health care products and services in an interactive environment.

B) This message can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses interactively with the possibility for automatic adjudication and an immediate response.

C)This message can be used for the administrative reimbursement of health care products and services for medical, hospital, dental, pharmaceutical and durable medical equipment claims.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has been developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)This standard is developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard:

A) The Interactive Healthcare Claim/Encounter (IHCLME) is not a guideline.

B)The message is expected to be approved as a Draft Standard for Trial Use (DSTU) in October 1997.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005 once approved.

D)This standard does not require an implementation guide. ASC X12 has published four Type II Tutorial reports or tutorials for version 003041 in October of 1994, version 003050 in October 1995, version 003051 in February 1996, and version 003060 in April of 1996. To facilitate consistent implementation across the health care industry, the X12 Insurance Subcommittee is currently in the process of completing five implementation guides for version 003070 encompassing medical, hospital, dental, pharmaceutical claims, and workers compensation jurisdictional reporting with an anticipated publication date of April 1997.

E)There will be only one implementation guide for the Interactive Healthcare Claim/Encounter (IHCLME).

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard has been defined and currently is undergoing review by the members of the X12 Health Care Task Group. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent subreleases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard, as well as, when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard must be balloted by ANSI X12 followed by a ballot within UN/EDIFACT.

BB) This message is expected to be approved as a Draft Standards for Trail Use (DSTU) in October 1997.

Indicator of Market Acceptance:

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Every government contractor has been funded by the Health Care Financing Administration (HCFA) to implement the ASC X12 standards. Many other payers have followed HCFA's lead and implemented the standards as well.

C)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards because costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity:

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

· Current Procedural Terminology (CPT) Codes from American Medical

Association

• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards:

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

A) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

B)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

C)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

ASC X12 Interactive Healthcare Claims Encounter (IHCLME) is used to transmit claims/encounters interactively, coordinating with the possibility for automatic adjudication and an immediate response. Identifying data requirements, determining business scenarios, grouping data needs into segments and defining the structure of the messages. Claims being considered for interactive transactions include pharmacy, institutional, professional and dental. One message will cover all four claim types. The response message covers the claim status and adjudication information. These will be EDIFACT messages utilizing ASC X12 data dictionaries. This message is currently under development.

National Council for Prescription Drug Programs (NCPDP)

The scope of the standards that NCPDP develops are those for information processing for the pharmacy services sector of the health care industry.

ANSI Accredited:

NCPDP was accredited by ANSI on August 6, 1996. The type of accreditation was the Accredited Organization Method.

NCPDP Standard Claims Billing Version 2.0

This batch format is compatible to and consistent with the standard Universal Claim Form to

enable logical progression from a manual paper claims submission system to an automated

billing process. The Standard Claims Billing format utilizes both data elements and program

logic that include the following items or understandings:

• Use of industry accepted data elements (National Drug Code Number (NDC), National Association of Boards of Pharmacy Number (NABP) Processor number, etc.).
• Contingency allowance for future enhancements.
• Compatibility of the format to most existing processing systems.

NCPDP Telecommunications Standard Format Version 3.2

NCPDP recommends the use of a standardized format for electronic communication of claims between pharmacy providers, insurance carriers, third-party administrators, and other responsible parties. This standard addresses the data format and content, the transmission protocol, and other appropriate telecommunication requirements and was developed to accommodate the eligibility verification process at the point-of-sale and to provide a consistent format for electronic claims processing. The standard supports the submission and adjudication of third party prescription drug claims in an on-line, real-time environment.

NCPDP Version 3 Release 2 was a standard created by the NCPDP Telecommunication Work Group (Work Group One). The objective of the standard is to provide a standard format for on-line real time adjudication for pharmacy claims. Functions include billing of pharmaceutical products including compound medications; billing of professional drug utilization review situations. Users of the standard include administrative/reimbursement and clinical environment. Pharmacies submit claims for drugs and professional services and when applicable receive clinical DUR information derived from payer/prescription benefit manager databases. The standard is used in all operating system environments and claims are submitted and then adjudicated directly from pharmacy to payer and via network. The standard satisfies the needs of public and private prescription benefit plans for well over 100,000,000 health plan members. In addition, this standard facilitates a specific type of business communication between a large number of diverse parties within the third party environment. To do this successfully, it must accomplish the following tasks:

• Support the needs of as wide a base of potential users as possible.
• Maximize use of existing relevant standards wherever possible (e.g. Version 1.0 of this standard).
• Be flexible enough to change as needs and technology change.
• Be unambiguous.
• Be easy to implement by payers and pharmacy management software developers.

User Environment:

A given organization might serve multiple roles (for example, Administrator and Processor). Certain roles might be split between multiple organizations, the administrator and processor could be different.

This standard addresses the submission of a claim and/or professional service by a dispenser to an administrator/processor, and identifies the response of the administrator/processor to the dispenser. For the purpose of this document, the term "processor" will be used to identify the identity actually performing the authorization/adjudication function.

Types of Messages:

This standard addresses two types of communication between the dispenser (sender) and the processor (receiver). These communication types are claim submission/response and claim reversal/response. These are described in detail below:

Claim Submission/Response:

This transaction is used by the dispenser to request the administrator verify the eligibility of a specific claimant according to the appropriate plan parameters. The message sent by the dispenser contains four types of data:

1) Control Data: This identifies the message type, destination, etc.

2) Dispenser Data: This identifies the provider of the service.

3) Claimant Data: This identifies the person for whom the service is being provided.

4) Prescription Data: This describes the specific service being provided by the Dispenser.

Each claim submission message contains control, dispenser, and claimant data, and up to four occurrences of prescription data. A special case message is where there are zero occurrences of the prescription data. This identifies a request to only verify the eligibility of the claimant.

Depending upon the particular claim submission message, the processor can provide one of the following general types of responses:

• Eligibility verification only- This occurs when the processor is verifying the eligibility of the claimant. The claim must be submitted for processing at another time.
• Claim capture only- This occurs when the processor acknowledges receipt of the claim, but is not making any judgment regarding eligibility of the claimant.
• Claim capture, eligibility verification, and adjudication- This occurs when the processor captures and processes the claim, and returns to the originator the dollar amounts allowed under the terms of the plan.

Claim Reversal/Response:

This transaction is used by the dispenser to request the administrator to reverse a previously submitted claim. The results of a successfully submitted reversal are as if the claim was not submitted in the first place. The message sent by the dispenser contains four types of data:

1) Control Data: This identifies the message type, destination, etc.

2) Dispenser Data: This identifies the provider of the service.

3) Prescription Data: This describes the specific service being provided by the Dispenser.

Each claim reversal message contains control, dispenser, and one occurance of prescription data.

The claim reversal response tells the dispenser if the administrator was able to reverse the claim or not.

Business Flow:

The prescription information is transmitted electronically either through a value-added network switch or directly to a payer or pharmacy benefit management company, where the various transaction functions described above are completed. A paid or rejected response is sent back either through a value-added network switch or directly to the pharmacy in a matter of seconds. This is completed in an on-line real-time environment.

Application Function/Domain Completeness:

Version 3.2 was completed in February 1992 and ongoing maintenance continues. A Drug Utilization Review (DUR) component and a Professional Pharmacy Services (PPS) component have been added to enhance the standard to fit the business needs of the pharmacy community. Drug Utilization Review provides information to the pharmacist regarding potential drug interactions of the prescription drug being billed with the claimant's drug history. In addition, a compound standard has also been developed.

TABLE OF NCPDP TELECOMMUNICATION

STANDARD VERSION/RELEASE

This standard has no competing standard to date. The membership of NCPDP has established this widely accepted and implemented standard for on-line real-time prescription claims processing. Implementing this standard required the coordinated efforts and timely response of software developers, payers/claims processors, managed care organizations, pharmacy providers, and numerous other organizations. This standard is being used to process over 1 billion prescription drug claims per year.

Readiness of Standard:

A)NCPDP Version 3.2 is not a guideline, but a completed standard. This standard was submitted recently to ANSI to become an American National Standard.

B)This standard has been implemented by the vast majority of the pharmacy benefits industry since 1992. It was developed to be a natural progression from the previously implemented version.

C)The standard can be obtained by contacting NCPDP's office at (602) 957-9105.

D)NCPDP Version 3.2 has a separate implementation guide. Work is under way for 3.3 and 3.4 implementation guides.

E)There is only one implementation guide. There are no major options that impact compatibility.

F)Yes, a conformance standard is specified (certification procedures). It is important to note that trading partners accomplish this, not NCPDP

G)Yes, conformance test tools are available.

H)The test tools are developed by trading partners based on business agreements.

I)The standard is complete and undergoes periodic enhancements.

J)A compound drug enhancement was recently completed, as well as different data elements for new versions and releases.

AA) A data element request form (DERF) process (data maintenance) has been developed at NCPDP to enable the standard to be modified by the NCPDP membership to fit the business needs of the industry.

BB) This standard is modified periodically upon review of DERFs.

Indicator of Market Acceptance:

A) The standard is virtually used by every pharmacy processor, PBM (Pharmacy Benefit Management Company) submitting on-line real-time pharmacy claims. Every Pharmacy Practice Management Software Vendor in the United States supports the standard. Over 1,000,000,000 claims from 100,000,000 health plan members were submitted in 1996 using the standard. The standard will be used in South Africa in early 1997. In addition, 43 State Medicaid Agencies utilize our standard for their business needs.

B)The language will be English only.

Level of Specificity:

A) Version 3.2 allows for both fixed length transactions or variable length transactions. Implementation of variable length transactions gives the sender and receiver the option of compressing or eliminating optional data elements to reduce message length where these data elements are not required by the processor. As of Version 3.3, fixed length transactions are no longer supported.

B)There is no implementation guideline for the Compound standard for V3.2. There is one for Compounds (V3.3) and Prior Authorization (V3.4).

A) Data sets referenced include :

1. FDA's National Drug Code (NDC)
2. NABP #s - National Association for Boards of Pharmacy Number, an universal identifier for pharmacies in the United States
3. DAW codes - Dispense as written codes

A) The code sets are updated as new data elements are approved by the membership.

A) The data dictionary can be acquired by contacting NCPDP's office at 602-957-9105.

A) There is an instruction sheet.

A) It is used by virtually all users of the standard. (in the hundreds).

I) It is not under development.

Relationships With Other Standards:

A) PPS and DUR are used as part of the NCPDP standard.

A) The X12 835 is used to report on the remittances for claims submitted.

A) Not applicable.

A) Not applicable.

A) No, this standard is not consistent with international standards.

A) There are no gaps.

A) Not applicable.

Identifiable Costs:

The costs for licenser, cost of acquisition, cost time frames for education, training, and implementation are contingent upon the usage and trading partner agreements.

Contact For More Information:

NCPDP, Inc. 4201 North 24th Street, Suite 365, Phoenix, AZ 850160-6268,

Phone (602) 957-9105,

Lee Ann C. Stember - President,

Daniel J. Staniec, R.Ph., MBA Executive Vice President of External Affairs

Health Care Financing Administration (HCFA)

ANSI Accredited:

Not ANSI accredited. Have not applied for accreditation.

HCFA National Standard Format (NSF), Version 002.00

Contact for More Information:

Joy Glass - Email Jglass@hcfa.gov, 410-786-6125, FAX 410-786-4047

Description of Standard:

The NSF consists of fixed-length (320 bytes) records. Each record has a unique identifier and logically related data elements.

A) Objective - The NSF was designed to standardize and increase the submission of electronic claims and coordination of benefits exchange.

B) Function - The NSF is used to electronically submit health care claims and encounter information from providers of health care services to payers. It is also used to exchange health are claims and payment information between payers with different payment responsibility.

C) User Environment - NSF users consist of a variety of health care providers, such as, professional, dental, chiropractic, Indian health service providers, and suppliers of medical equipment and supplies. A variety of payers also use the format to exchange claim and payment information.

D) Systems Environment - The NSF is a file format and is platform/operating system independent.

E) Application Function/Domain Completeness - All codes used in the NSF are complete.

A) The NSF is "user friendly" and easily implemented. It contains detailed record and data descriptions as well as unambiguous data definitions. It is widely used by providers of health care and payers. In FY96, 668,650,936 Medicare claims were submitted electronically. Ninety eight (98) percent of those claims were in the NSF. The NSF does not have to be translated prior to application processing. The use of compression techniques eliminates at least 50% overhead when transmitting the NSF. With compression, the NSF is more economical than an ANSI X12 837 to transport.

Readiness of Standard:

A)The NSF is a guideline for building electronic claims. The NSF supports policy requirements for users. The NSF defines processes using validation statements. The NSF provides a structured design for building claims.

B) The NSF was fully implemented for Medicare in 1991 and continues to be supported. The NSF has been implemented by about 200 other payers.

C)The NSF is available on the HCFA BPO bulletin board 410-786-0215. The file name is NSF.EXE and is located in area 3. There are no restrictions and it is free of charge.

D) The NSF implementation guide is built into the specifications and people may build standard claims from it.

E) Some payers provide a guide to identify payer specific requirements.

F) The NSF specifies conformity. Because it is in the public domain some people choose not to conform. This would easily be fixed if it was recognized by Federal statute. The specifications are clear and conformity is easy to achieve.

G) HCFA's Office of Analysis and Systems has developed a software conformance/enforcement tool for the NSF.

H) Other Indicators of Readiness: The NSF has been available since 1991.

Indicator Of Market Acceptance:

1)Medicare implemented the standard in 1991. Copies of the NSF are requested almost daily. The NSF is available on a bulletin board. Diskettes were previously distributed. Since the NSF is free of charge, the number of copies distributed is not maintained.

2)The following government agencies have implemented the NSF:

a) Medicare

b)Medicaid

c)Indian Health Services

d)Champus

e)Numerous Blue Shield plans and some 200 organizations use the NSF.

1) We are not aware of other countries that implemented the NSF.

2)We constantly receive praise from software vendors, clearinghouses and health care providers regarding the usefulness of the NSF and ease of implementation.

Level of Specificity:

A)The NSF is very detailed. Record descriptions exist, as well as, unambiguous data element definitions and format descriptions.

B)The NSF framework is detailed down to the smallest named unit of information.

C)The NSF does not reference or assume other standards to achieve more specificity.

D thru H) The NSF includes a code set for the place of service, podiatry codes, and type of service. The NSF assumes the following codes sets:

Relationship With Other Standards:

A. The ANSI X12 837 health care claim is not suitable for use in an application program and must be translated into the NSF prior to claims processing. The NSF does not have to be translated and, in turn, reduces administrative costs.

Identifiable Costs:

The NSF is distributed free of charge. The NSF can be implemented within 3 to 6 months of receipt of the standard specifications. Implementation costs vary depending on how a payer implements the standard. Health care provider costs are minimal. The average cost for software is less than $200, and sometimes as little as $25.00. Implementation costs can range from $100,00 to $500,000. If a complete system rewrite is performed, the cost could be $500,000. If the change is at the interface, the cost could be less than $100,000. These costs include comprehensive systems testing.

HCFA Uniform Bill-92 (UB-92), Version 4.1

Contact For More Information:

Jean M. Harris - Email JHarris2@hcfa.gov, 410-786-6168, FAX 410-786-4047

Description of Standard:

The UB92 consists of fixed-length (192 bytes) records. Each record has an unique identifier and logically related data elements.

Objective - The UB92 was designed to standardize and increase the submission of electronic claims and coordination of benefits exchange.

Function - The UB92 is used to electronically submit claims for health care received in an institutional setting to payers. It is also used to exchange health Care claims and payment information between payers with different payment responsibility.

User Environment - UB92 users are institutional providers. A variety of payers also use the format to exchange claim and payment information.

Systems Environment - The UB92 is a file format and is platform/operating system independent.

Application Function/Domain Completeness - All codes used in the UB92 are complete.

The UB92 is "user friendly" and easily implemented. It contains detailed record and data descriptions as well as unambiguous data definitions. It is widely used by providers of health care and payers. It is conservatively estimated that 60,000 providers use the UB92. In FY96, 141,872,119 Medicare institutional claims were submitted electronically. Ninety six point eight (96.8) percent of those claims were in the UB92. The UB92 does not have to be translated prior to application processing. The use of compression techniques eliminates at least 50% overhead when transmitting the UB92. With compression, the UB92 is more economical than an ANSI X12 837 to transport.

Readiness of Standard:

A. The UB92 is a guideline for building electronic claims. The UB92 supports policy requirements for users. The UB92 defines processes using procedure statements.

B. The UB92 was fully implemented for Medicare in 1993 (the UB83 was implemented in 1983) and continues to be supported. The UB92 has been implemented by about 73 other major payers.

C. The UB92 is available on the HCFA BPO bulletin board 410-786-0215. The file name is UB92BBS.EXE and is located in area 3. There are no restrictions and it is free of charge.

D. The UB92 implementation guide is built into the specifications, and people may build standard claims from it.

E. Some payers provide a guide to identify payer specific requirements.

F. The UB92 specifies conformity. Because it is in the public domain some people choose not to conform. This would easily be fixed if it was recognized by Federal statute. The specifications are clear and conformity is easy to achieve.

G &

H. HCFA's Office of Analysis and Systems has developed a software conformance/enforcement tool for the UB92.

I thru

M. The UB92 has been available since 1993.

Indicator of Market Acceptance:

A. Medicare implemented the standard (UB83) in 1983. Copies of the UB92 are requested frequently. The UB92 is available on a bulletin board. Diskettes were previously distributed. Since the UB92 is free of charge, the number of copies distributed is not maintained.

B. The following government agencies have implemented the UB92:

• Medicare
• Medicaid

Numerous Blue Cross plans use the UB92. Approximately, 73 other payers have implemented the standard.

C. We are not aware of other countries that implemented the UB92.

D. We constantly receive praise from software vendors, clearinghouses and health care providers regarding the usefulness of the UB92 and ease of implementation.

Level of Specificity:

A. The UB92 is very detailed. Record descriptions exist, as well as unambiguous data element definitions and format descriptions.

B. The UB92 framework is detailed down to the smallest named unit of information.

C. The UB92 does not reference or assume other standards to achieve more specificity.

D thru

H. The UB92 includes a code set for the patient status, accommodation revenue codes, ancillary revenue codes, and condition codes. The UB92 assumes the following code sets:

Relationship with Other Standards:

A. The ANSI X12 837 health care claim is not suitable for use in an application program and must be translated into the UB92 prior to claims processing. The UB92 does not have to be translated and, in turn, reduces administrative costs.

Identifiable Costs:

The UB92 is distributed free of charge. Typically, it takes one year from statement of intent for the UB92 to be in full production. Implementation costs vary depending on how a payer implements the standard. If a complete system rewrite is performed, the cost could be $1,000,000. If the change is at the interface, the cost could be as little as $100,000. These costs include comprehensive systems testing.

American Dental Association (ADA) Accredited Standards Committee MD 156

The American Dental Association (ADA) is sponsor and secretariat of the Accredited Standards Committee (ASC) MD156 for Dental Materials, Instruments and Equipment. In 1992 there was interest in the standardization of clinical information systems. After evaluating current informatics activities, the ADA initiated several projects relating to clinical technology. A task group of the ASC MD156 was created by the Association to initiate the development of technical reports, guidelines, and standards on electronic technologies used in dental practice.

Components of the task group include five working groups for clinical information systems. The working groups were established to promote the concept of a dental computerized clinical work station and allow the integration of different software and hardware components into one system in order to provide for all of a clinician's information needs. Clinical information systems include all areas of computer-based information technologies such as digital radiography, digital intraoral video cameras, digital voice-text-image transfer, periodontal probing devices, CAD/CAMs, etc. By establishing standards for these modules, the need for several stand-alone systems in the dental office will be eliminated.

Each working group encompasses a broad spectrum of projects under a central theme. Within each working group, subcommittees are responsible for the specific projects. Each subcommittee has been researching standards already in existence to determine if they could be applicable to dentistry. Participants are also interfacing with standards groups active in medical informatics.

The ADA also sponsors participation in ANSI activities of the International Organization for Standardization (ISO) Technical Committee 106 on dentistry and acts as secretariat for ANSI for Working Group 2 of ISO/TC 106. Thus, the ADA works both nationally and internationally in the formation of standards for dentistry.

ANSI Accredited:

The American Dental Association has been sponsoring a standards program for dental materials, instruments and equipment since 1928. From 1928 to 1953, all specifications for dental materials, instruments and equipment were developed at the National Bureau of Standards by the federal government in cooperation with the ADA. Between 1953 and 1970, the Dental Materials Group of the International Association for Dental Research (IADR) acted as advisor to the ADA in developing specifications. In 1970, American National Standards Committee MD156 (ANSC MD156) was established by the American National Standards Institute, replacing the Dental Materials Group.

In 1983, the ANSC MD156 became an accredited committee by ANSI making the committee the Accredited Standards Committee MD156 (ASC MD156).

To date, 56 specifications for dental materials, instruments and equipment have been adopted by ANSI as American National Standards. In addition, the ADA acts as proprietary sponsor on a project to handle standards for dental radiographic film. This activity is conducted under the Accredited Canvas Method of ANSI.

ADA Implementation Guide for ASC X12 837

The standards which are being developed for electronic insurance transactions focus on the "envelope" used to transmit data electronically. The ADA has been working with the ASC X12 in order to define the data content placed in that envelope. The ADA has been responsible for the data content as it pertains to dental claims while the National Uniform Claim Committee (NUCC) and the National Uniform Billing Committee (NUBC) focus on the non-institutional and institutional data sets.

The ADA released an Implementation Guide for dental claims submission based upon the ANSI ASC X12 837 transaction set. The Association provided the data content for a dental claim based upon the ADA Dental Claim Format for the Implementation Guide. The Guide will assist practice management vendors, third-party payers and clearinghouses in the execution of the ASC X12 standards. Future versions of the 837 Dental Implementation Guide will be developed by ASC X12. However, the ADA will continue to provide the data content for the development of an Implementation Guide for dental applications.

The ADA developed two versions of the Implementation Guide (Versions 3041 and 3051) which were adopted by the ASC MD156 and recommended for use by practice management vendors for electronic dental claims transactions. Future versions of the Guide will be developed within the ASC X12. However, the ASC MD156 will continue to work with the ASC X12 Insurance Subcommittee.

1) ANSI/ADA 1000 A Standard Clinical Data Architecture for the Structure and Content of a Computer-based Patient Record. Detailed information pertaining to the ANSI 1000 standard is included in Appendix B entitled Activities to Promote Interoperability of Standards - Frameworks, Architectures, and Models.

Description of Standard:

The ADA Dental Implementation Guide is based upon the ASC X12 837 claims submission transaction. It was developed to assist users such as practice management vendors, third-party payers, and clearinghouses, in the execution of the 837 for dental claims transactions.

Readiness of Standard:

The ASC X12 claims submission 837 is being used for submitting some dental claims. However, utilization of the standard is very low at this time. Currently, most dental claims are submitted using proprietary formats. The 837 is the first standard to be developed for claims transactions. Therefore, the Association encourages that electronic dental claims transactions continue to be submitted in the current electronic formats, whether the transactions are proprietary formats or the 837, and a migration should occur to require ASC X12 formats only. The 837 transaction is the only approved ANSI draft standard for trial use. However, the ASC X12 Interactive Claim standard will soon be finalized and when approved it will be the preferred standard to be used for dental claims transactions.

Identifiable Costs:

The ADA's Implementation Guide version 3051 is free of charge from the ADA. Future versions of the Dental Implementation Guide will be available through DISA.

Contact For More Information:

Health Level Seven, Inc. (HL7)

Category/Classification of Standard

• Health Claims Or Equivalent Encounter Information - Health Level Seven provides healthcare organizations such as hospitals and clinics the ability to consolidate patient billing information between computer systems. HL7 also provides the ability to transmit appropriate healthcare claims to the Health Care Financing Administration using their proprietary formats: UB82 for HL7 Versions 1.0 through 2.1 and the UB92 for HL7 Versions 2.2 and 2.3. In particular the UB82 part of the HL7 Standard predates the X12 835 transaction set by five years. If "equivalent encounter information" is to mean the clinical data associated with an encounter, then HL7 is currently uniquely positioned to have an existing standard to send this data. It is reasonable to expect that this type of clinical data would be included in the NCQA and HEDIS reporting requirements.
• Health Claims Attachments - In all versions, HL7 provides data interchange formats for consolidating patient-specific clinical information to support most healthcare claims, including physician's orders, prescriptions, laboratory and clinical tests, diagnostic procedures (excluding imaging) and resulting outcomes. HL7 version 2.2 is the only ANSI approved clinical data interchange standard in these areas. HL7 has also defined segments to transmit data (including clinical data) associated with an injury or accident.
• First Report Of Injury - In collaboration with the Centers for Disease Control (CDC), Health Level Seven is developing an Emergency Room data interchange format to report specific first encounter disease information.
• Referral Certification And Authorization - Health Level Seven has specific segments and trigger events to perform the data interchange necessary for referral and authorization. This request most frequently requires detailed clinical data over several encounters. Health Level Seven is uniquely positioned to meet these requirements.

Health Level Seven became an ANSI accredited SDO, Accredited Organization Method, on June 12, 1994.

Health Level Seven Versions 1.0 through 3.0

1)Health Level Seven Version 1.0 (published in 1987)

2)Health Level Seven Version 2.0 (published in 1989)

3)Health Level Seven Version 2.1 (published in 1990)

4)Health Level Seven Version 2.2 Application Protocol for Electronic Data Exchange in Healthcare (published in 1994, ANSI approved on February 8, 1996)

5)Health Level Seven Version 2.3 Application Protocol for Electronic Data Exchange in Healthcare is currently in the final stages of revision (expected publish date is March, 1997; currently in process for ANSI approval)

6)Health Level Seven Version 3.0 Application Protocol for Electronic Data Exchange in Healthcare is in the development stage (anticipated publish date is December 1998)

Contact For More Information:

Mark McDougall

Executive Director

Health Level Seven

3300 Washtenaw Avenue, Suite 227

Ann Arbor, MI 48104-4250

Phone: (313) 677-7777

Fax: (313) 677-6622

E-mail: hq@hl7.org

Description of Standard:

Objectives

To facilitate the interchange of health informatics and administrative and financial data needed to support clinical practice. By creating messages with sufficient granularity of data to support clinical practices, HL7 also creates support for the interchange of health informatics data needed for research (e.g., clinical trials messages; the use of the results messages to build clinical research databases), public health (e.g., the use of immunization query/reporting to track immunization needs of populations, the use of product experience messages to support drug and equipment adverse effects), and epidemiology (detailed clinical data can be collected on specific diseases).

Functions

HL7 supports the following functions. (Please refer to Attachments 1 and 2 for a complete listing of HL7 event type codes and HL7 order control codes, respectively; to Attachment 3 for a listing of UB2 segments; and to Attachment 4 for product experience segments.) Those specific to Version 2.3 are denoted by an asterisk (*):

• Administrative functions, including messages for:
• administrative support for clinical practice
• ADT (admitting, discharge, and transfer within an institution)
• registration (inpatient, outpatient, group and private practice)
• Financial support for clinical practice including:
• notifying a billing/financial system of work performed
• adding / updating patient accounts
• purging patient accounts
• generating bills and accounts receivable statements (a display query)
• generating and transmitting UB92 data (including charges, payments and adjustments)
• updating account*
• ending account*
• Scheduling*, including resources for:
• inpatient
• outpatient
• clinic
• private practice
• Orders, including but not limited to:
• clinical laboratory
• radiology
• pharmacy (various types and levels including inpatient and outpatient)

· EKG

· EEG

• dietary
• requisitions
• Results, including, but not limited to:
• clinical laboratory
• radiology
• pharmacy
• images (by reference in HL7 Version 2.2, and directly in HL7 Version 2.3)
• discharge summaries
• op-notes
• clinic notes
• pharmacy administrations
• Support for reporting results containing waveform data* (e.g. EEG, ICU 'strip' data, etc.)
• Immunization queries and reporting*, including
• patient identification
• next of kin
• patient visit
• insurance information
• common order
• pharmacy administration
• pharmacy route
• observation/result
• notes (regarding immunization)
• Clinical trials definition and reporting*
• Product experience reporting* (e.g. adverse drug/equipment reporting messages), including
• sender
• observation
• causal relationship
• product summary
• product detail
• facility
• Clinical master files support
• Clinical referrals*
• Problems, goals, and pathways*
• Clinical transcription*
• General query support for all of the above areas in both display and record-oriented formats

User Environment

The user environment for HL7 includes administrative, financial, and clinical information in support of clinical practice, research, adverse product experience, and epidemiology. The specific user 'environments' include any settings where this type of information needs to be transmitted between healthcare applications, such as:

• hospitals
• groups of hospitals (with associated clinics, and associated private or small practice groups)
• clinics
• private practices
• small group practices

Specific applications environments/settings where HL7 is currently being used include: workstation/desktop applications; message routing applications (e.g. 'gateways,' communications components such as the Andover Working Group's "Enterprise Communicator"), clinical data repositories (important components of the 'electronic medical record'), and systems comprised of these three software 'tiers.' Some of these already operate over the Internet.

Systems Environment

HL7 is a specification for healthcare informatics messages to be sent between applications, and thus, has no specific requirements for any of the above (i.e. no specific requirements for operating systems, network, hardware or other requirements). However, the HL7 Versions 2.2 and 2.1 do require an ASCII-based message encoding syntax, which is defined in Chapter 2 of the standard. HL7 Version 2.3 allows non-ASCII encoding schemes as defined in Chapter 2 of the standard, but does not directly support binary data. (Binary data objects may be referenced in HL7 Version 2.2 messages via the use of the 'Reference Pointer' data type.) HL7 Version 2.3 does contain a specific data type (ED, for encapsulated data) which allows for a MIME-encoding of binary data. By using this method, binary data may be transmitted in HL7 Version 2.3 messages.

It is important to note that even within HL7 Versions 2.1-2.3, the messages are defined abstractly, without reference to a specific encoding syntax. This allows implementors to use non-HL7 encoding syntaxes as needed (e.g., there is an HL7 Version 2.2 implementation using ASN.1 BER encoding syntax). This same paradigm will be followed in Version 3.0: the messages will be defined without regard to the encoding syntax used to send them between applications.

Although its messages will be defined abstractly, HL7 Version 3.0 plans to support 4 different 'encoding' layers: character based (an improved version of the current Version 2 encoding syntax), CORBA, OLE, and EDIFACT.

Application Function/Domain Completeness

With HL7 Version 2.3, HL7 has doubled the scope of messages supporting clinical practice, and the administrative and financial data needed to support clinical practice. HL7 believes that the core areas of clinical data are covered at this point. However, there is additional work to be completed. The members of HL7 have created the following special interest groups (SIGs) to define and research additions to the specification. The SIGs will determine if the area of interest can be addressed within one of the current HL7 technical committees, or whether a new technical committee needs to be formed. The list of current HL7 SIGs gives an indication of future areas that HL7 will address:

• Object brokering technologies (OBT) SIG (CORBA, OLE). Their goal is to demonstrate "proof of concept" for new technologies. A second demonstration was held at HIMSS '96. Full HL7 support requires completion of the HL7 object data model. The Andover Working Group is using a version of this approach that supports both CORBA and OLE versions of HL7 Version 2.2 messages.
• Automated Data (enhanced coverage of waveforms, ICU-systems, etc.)
• Home Health
• Image Management (with DICOM and related input)
• Professional Certification
• Security
• Codes and Vocabularies
• Clinical Decision Support (e.g. Arden Syntax)

· SGML

In addition, the Quality Assurance/Data Modeling technical committee, which is doing the bulk of the work on the methodology for HL7 Version 3.0, will split into two separate technical committees, one concerned with the Version 3.0 methodology (including object data modeling), and the other concerned with quality assurance.

HL7 Version 3.0 will be based on an object modeling framework, including the message development framework created by the IEEE Joint Working Group on the Common Data Model, and also using work developed by CEN TC-251, WG-3, Project Team 25, for developing messages from object models. This work has been expanded and adapted to HL7's needs by HL7's Quality Assurance/Data Modeling technical committee. Many of the relevant documents are available on the Duke University Healthcare Informatics Standards Web Site (use http://www.mcis.duke.edu/standards/guide.htm for all standards, and use http://www.mcis.duke.edu/standards/HL7/hl7.htm for just HL7). In addition to the Message Development Framework and detailed instructional materials, HL7 has created a Reference Information Model that will be used to define and harmonize sub-models for each technical committee. Over the next year to 18 months, HL7 will use this work to develop Version 3.0.

The Version 3.0 approach has been demonstrated at two HIMSS's conferences and validated by the work of the Andover Working Group in their Enterprise Communicator specification and implementation. (Supported already by over 100 vendors and institutions.)

Way(S) In Which This Standard Is Superior To Other Standards In This Category/Classification

The HL7 standard is superior in its completeness of coverage of scope of messages supporting clinical practice, and the administrative and financial data needed to support clinical practice. It has gained market acceptance and very widespread use, not only within the U.S., but internationally in such countries as Canada, The Netherlands, Germany, Australia, New Zealand, Finland and Japan. It provides ease of implementation, flexibility, and has gained acceptance by major vendors and academic sites.

Other Relevant Characteristics

HL7 is actively working to harmonize its work with other SDO's and with other relevant areas. For example, HL7 recently formed a codes and vocabularies SIG which will work to standardize the code sets in use for clinical data fields and transactions. HL7 is participating in the IEEE JWG/Common Data Model and convenes meetings jointly with X12N. HL7 has an MOU with NCPDP and is working to harmonize the NCPDP's SCRIPT specification with the HL7 Pharmacy messages.

Readiness of Standard:

Is It A Guideline?

HL7 is not a guideline, but an actual standard for healthcare informatics messages supporting clinical practice, and the administrative and financial data needed to support clinical practice. Insofar as HL7 Version 2 messages are based on 'trigger events,' they address actual processes within the healthcare environment. HL7 Version 3.0 will be based on objects derived from analysis of scenarios and business cases in the healthcare environment: in that sense Version 3.0 will address actual processes of information flows within the healthcare environment. The exchange of such information can be used to support clinical practice, but does not per se, define practice. In the same sense, HL7 messages do not imply the design of applications, but can be used to create or request data which is needed by healthcare clinical applications.

Is It Implementable?

HL7 Versions 2.1 and 2.2 are fully implementable, since they have been balloted standards since 1990 and 1994 respectively. In addition to the standards themselves, HL7 has published Implementation Guides for Version 2.1 and 2.2. HL7 Version 2.3 will be finalized during the first quarter of 1997, at which time it will be fully implementable. As with Versions 2.1 and 2.2, HL7 will publish an Implementation Guides for Version 2.3. There are thousands of installations using HL7 Version 2.1 and 2.2, and many sites using 2.3 draft versions. In addition, an Access database will be available with Version 2.3 to help users create their own interface specifications. This database consists of tables for HL7 components, tables, fields, messages and segments and includes several predefined queries (e.g., alpha sort of tables, numeric sort of tables,

fields and components, etc.).

Version 3.0 is planned for release during the fourth quarter of 1998 and will provide both a standard and an Implementation Guide. In addition, formal conformance profiles will be available for Version 3.0.

How Can The Standard Be Obtained?

Copies of the HL7 standard V2.1, 2.2, and 2.3 are available for $125 each from HL7 Headquarters at:

3300 Washtenaw Avenue, Suite 227

Ann Arbor, MI 48104-4250

Phone: (313) 677-7777

Fax: (313) 677-6622

E-mail: hq@hl7.org

Does This Require A Separate Implementation Guide?

HL7 has published Implementation Guides for Version 2.1 and 2.2. HL7 Version 2.3 will be published during the first quarter of 1997, at which time it will be fully implementable. As with Version 2.1 and 2.2, HL7 will publish an Implementation Guide for Version 2.3.

Is There Only One Implementation Guideline?

For the 2.x versions of HL7 there is a single Implementation Guide. Version 3.0 will provide four Implementation Guide sections, one for each of the four implementable message specifications: character-based; OLE, CORBA, and OLE.

Is A Conformance Standard Specified?

The Conformance SIG is working on this part of the standard. A conformance standard will definitely be provided for Version 3.0, and the Conformance SIG may also develop conformance standards for HL7 Versions 2.x.

Are Conformance Test Tools Available?

Conformance test tools will be part of Version 3.0, and the Conformance SIG may also develop them for Version 2.3.

Source Of Test Tools?

The source of HL7 V3.0 test tools has not yet been selected. Additionally, the Conformance SIG may develop or contract them for Version 2.3.

If The Standard Is Under Development, What Parts Of It Are Ready Now?

Version 2.1 and 2.2 are available now; Version 2.3 is currently available in draft form and will be available in its final, published form during the first quarter of 1997.

What Extensions Are Now Under Development?

As indicated earlier, these include:

• Object brokering technologies
• Automated Data (enhanced coverage of waveforms, ICU-systems, etc.)
• Home Health
• Image Management (with DICOM and related input)
• Professional Certification
• Security
• Codes and Vocabularies
• Clinical Decision Support (e.g. Arden Syntax)

· SGML

· Andover Working Group's "Enterprise Communicator"

Major Milestones Toward Standards Completion?

Version 2.3:

· Final balloting

Version 3.0

• Completion of the "Strawman" Reference Information Model
• Completion of the Hierarchical Message Descriptions
• Completion of Implementable Message Specifications for OLE/CORBA and printable character streams

Projected Dates For Final Balloting And/Or Implementation.

• V2.3 - Final balloting will be completed by mid January, 1997. Anticipated publish date is March, 1997.
• V3.0 - Work will begin in January, 1997 with the objective of having the first ballots completed by the end of 1998.

Other Indicators Of Readiness That May Be Appropriate.

One company has been using the proposed Referral chapter specification (new with Version 2.3) in two state-wide and three regional healthcare information networks for the past two years. Much of the information in this chapter was derived from prototyping the work being accomplished in these information networks. They have utilized inter-enterprise transactions for 80% of the events in the Referral chapter. In addition, one hospital vendor has implemented the Scheduling transactions (also new with Version 2.3) and has been using them successfully since January, 1996.

Indicators of Market Acceptance:

Based on our membership records of over 1,600 total members in HL7, approximately 739 vendors, 652 healthcare providers, 104 consultants, and 111 general interest/payor agencies are utilizing the HL7 standard. HL7 standards have been installed thousands of times. For example, one vendor alone has installed 856 interfaces per HL7 standards as of mid 1996. In addition the HL7 standard is being used and implemented in Canada, Australia, Finland, Germany, The Netherlands, New Zealand, and Japan.

Another relevant indicator of market acceptance in the public sector is the Andover Working Group's implementation of the Enterprise Communicator (and the accompanying tightly coupled, zero optionality conformance specification for sections of HL7 Version 2.2): the Andover Working Group is a 'test implementation' of the Version 3.0 functionality (it has CORBA, OLE, and character-based encoding structures, and is scheduled for production during the fourth quarter of 1996 or the first quarter of 1997.

Level of Specificity:

Description Of Framework Detail And Level Of Granularity.

The granularity of the HL7 standard is sufficient to support clinical practice (i.e., it is much more granular that the reimbursement standards). It's framework, in terms of scope, is also sufficient to support clinical practices.

Does The Standard Reference Or Assume Other Standards To Achieve More Specificity?

The HL7 standard does not reference or assume other standards to achieve more specificity. HL7 is, in general, more granular than other standards. It allows the use of standard code sets as needed by implementors via the HL7 CE data type.

Assumed Code Sets.

Current HL7 assumes code sets for a small number of single 'data elements.' These are termed 'HL7 tables,' and are so marked and so defined within the current specification.

For other data elements, HL7 allows the use of either 'site-defined' (e.g., HL7 IS data type) or 'standard (external) code sets' (e.g., using the CE coded element data type).

HL7 has hundreds of users who are using the HL7 tables.

Sources Of Code Sets.

HL7 tables are defined within the HL7 standard. User defined tables are defined at implementation time. Standard (external) tables (e.g. SNOMED, ICD9, CPT) are defined externally by their source-creating institutions, and may be obtained from their usual suppliers.

Available Assistance On The Use Of Code Sets.

It is expected that the new HL7 Codes and Vocabularies SIG will make recommendations for code sets, including means for obtaining the various standard external code sets. It is also expected that Version 3.0 will specify more completely all three types of code sets (HL7, user-defined, and external standards). Chapter 7 contains an extensive list of external standard code sets (including where to obtain them).

Projected Dates Of Completion And Implementation For Code Sets Currently Under Development.

The vocabulary SIG is expected to publish these dates sometime after the January 1997 HL7 meeting.

Relationships With Other Standards:

Other Standards

• HL7 and X12N. No overlap.
• HL7 and NCPDP Script. Conceptual overlap in the area of prescription messages (including authorization and refills).
• HL7 and ASTM Lab information and Waveform messages. Conceptual overlap.

Standards Reconciliation Or Coordination Activities

• HL7 and X12N are convening simultaneously so that members may attend and learn what each group is doing. Harmonization at the object model level is being addressed in that both groups are members of the IEEE-JWG/Common Data Model. Both groups have agreed not to create overlapping, redundant messages. HL7 and NCPDP have created an MOU and are working to harmonize the NCPDP script messages and the HL7 Pharmacy messages in terms of content and vocabulary so that a one-pass, unambiguous, translator can translate from one form to another. (The market dictates this approach.)
• HL7 and ASTM lab messages have been harmonized by having members of both groups work on both standards, thus guaranteeing interoperability.
• HL7 and ASTM waveform messages have been harmonized by having members of both groups work on both standards, thus guaranteeing interoperability.
• HL7 and IEEE Medix have been co-meeting and working with the IEEE JWG/CDM to harmonize their data models.
• HL7 has been harmonizing with DICOM via the HL7 IMSIG (Image Management SIG).
• HL7 is working with various groups to harmonize code sets/vocabularies for clinical data.
• HL7 has also been engaged in unofficial coordination with CEN TC 251 WG3 by sharing members working on various projects (including US 'experts' attending WG3 meetings). HL7 would also like to do some formal reconciliation of the object data models used by WG3.

What Portion Of The Specification And Functionality Is Affected By This Coordination?

(See above).

What Conditions Are Assumed In Order For This Coordination To Be Effective?

Cooperation and openness from the other SDO's.

Is This Standard Consistent With International Standards? If So, Which Standards?

In terms of the scope of HL7, to our knowledge there are no ISO standards that cover the HL7 scope (see definition above). Version 3.0 will be compatible with EDIFACT, CORBA and OLE as encoding syntaxes. Additionally, the Andover Working Group has demonstrated a means to use CORBA or OLE with Version 2.3 messages.

What Gaps Remain Among Related Standards That Should Be Addressed?

Agreement on standard code sets/terminologies for various clinical items need to be addressed. In addition, the listing of HL7 SIGs above identifies gaps in the clinical support coverage.

Describe What Is Being Done To Address These Gaps.

See above.

Attachment 1

HL7 Event Type Codes

Attachment 2

HL7 Order Control Codes and Their Meaning

Attachment 3

UB92 Segments

The UB2 segment contains data necessary to complete UB92 bills. Only UB92 fields that do not exist in other HL7 defined segments appear in this segment. Patient Name and Date of Birth are required; they are included in the PID segment and therefore do not appear here. When the field locators are different on the UB92, as compared to the UB82, the element is listed with its new location in parentheses ( ).

UB2 attributes

PID attributesFigure 3-2. PID attributes

Attachment 4

Product Experience Segments

PES - product experience sender segment

PES attributes

PEO - product experience observation segment

Details related to a particular clinical experience or event are embodied in the PEO segment. This segment can be used to characterize an event which might be attributed to a product to which the patient was exposed. Products with a possible causal relationship to the observed experience are described in the following PCR (possible causal relationship) segments. The message format was designed to be robust and includes many optional elements which may not be required for a particular regulatory purpose but allow a complete representation of the drug experience if needed.

A PEX message can contain multiple PEO segments if the patient experienced more than one event but must contain at least one PEO segment.

PEO attributes

PCR - possible causal relationship segment

The PCR segment is used to communicate a potential or suspected relationship between a product (drug or device) or test and an event with detrimental effect on a patient. This segment identifies a potential causal relationship between the product identified in this segment and the event identified in the PEO segment.

More than one PCR segment can be included in the message if more than one product is possibly causally related to the event.

PCR attributes

PSH - product summary header segment

PSH attributes

PDC - product detail country segment

PDC attributes

FAC - facility segment

FAC attributes

National Uniform Claim Committee (NUCC)

The National Uniform Claim Committee was organized in May 1995 to develop, promote, and maintain a standard data set for use by the non-institutional health care community to transmit claim and encounter information to and from all third-party payers. The data set includes data elements, definitions, and code sets. Providers and suppliers may submit the NUCC data set using either a paper or electronic envelope.

The NUCC has received a formal consultative role regarding standards for health care transactions selected by the Secretary of Health and Human Services (HHS) as specified in the administrative simplification section of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191). As specified in Act, American National Standards Institute (ANSI) accredited organizations must consult with the NUCC, the National Uniform Billing Committee (NUBC), the Workgroup for Electronic Data Interchange (EDI), and the American Dental Association (ADA). If the Secretary selects a standard different from one developed by an ANSI-accredited organization, she also must consult with the NUCC, NUBC, WEDI, and ADA.

The NUCC is chaired by the American Medical Association (AMA) with the Health Care Financing Administration (HCFA) as a critical partner. The Committee includes representation from key provider and payer organizations, as well as standards setting organizations, state and federal regulators, and the NUBC. As such, the NUCC is intended to have an authoritative voice regarding national standard data content and data definitions for non-institutional health care claims and encounters. The following organizations serve on the Committee as voting members:

• American Medical Association
• Health Care Financing Administration
• Alliance for Managed Care
• American Association of Health Plans
• ANSI ASC X12 Insurance Subcommittee
• Blue Cross and Blue Shield Association
• Health Insurance Association of America
• Medical Group Management Association
• National Association for Medical Equipment Services
• National Association of Insurance Commissioners
• National Association of State Medicaid Directors
• National Uniform Billing Committee

The NUCC will finalize its recommended data set in the first quarter of 1997 and make it available to the public. The NUCC also will provide formal comments into the ANSI ASC X12 Professional Implementation Guide for the Claim (837). Subsequently, the NUCC will address all other transactions specified in P.L 104-191.

ANSI Accredited:

The NUCC is not ANSI accredited; however, ANSI ASC X12 Insurance Subcommittee is a voting member of the NUCC, and several NUCC members are active in X12 and the HISB and are members of ANSI.

National Uniform Claim Committee Recommended Data Set for a Non-Institutional Claim or Encounter

Description of Standard:

The NUCC data set is intended for the transmission of claim and encounter information to and from all third-party payers, regardless of whether the envelope is paper or electronic.

Readiness Of Standard:

The NUCC will make its recommendation available to the public in the first quarter of 1997.

Identifiable Costs:

No or minimal costs.

Contact For More Information:

Mark J. Segal, Ph.D.

Chair, National Uniform Claim Committee

Director, American Medical Association

515 N. State Street

Chicago, IL 60610

Phone: 312/464/4726

Fax: 312/464/5836

eMail: Mark_Segal@ama-assn.org

Indicator Of Market Acceptance:

Voting members of the NUCC represent key provider and public and private payer organizations. Constituencies of these organizations were surveyed twice during the development of NUCC recommendations.

Health Claim Attachments

There are several standards developing organizations working on clinical data models, technical reports, guidelines and standards for clinical data. Some of these SDOs include HL7, ADA, X12, IEEE, ACR/NEMA/DICOM, and ASTM. Information regarding some of the standards being developed by HL7 and ADA appeared in the previous claims and encounter section and detailed information regarding their other projects appears in the Appendix explaining the activities to promote interoperability of standards - frameworks, architectures and models. Additional information regarding ASTM appears in the Security section. Claim attachment information pertaining to X12, IEEE, DICOM, and ASTM standards is listed below.

Accredited Standards Committee (ASC) X12 Insurance Subcommittee, Health Care Task Group.

ANSI Accreditation - X12 was accredited as an ANSI accredited standards committee in 1979. Subsequent X12 procedure changes have required ANSI re-accreditation which was last granted in 1987.

The main objective of ASC X12 is to develop Electronic Data Interchange (EDI) standards to facilitate electronic business transactions (i.e. order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions). ASC X12 endeavors to structure standards in a manner that computer programs can translate data to and from internal formats without extensive reprogramming.

This strategy allows companies to maximize their resources required for internally developed or commercial software (recommended) and private or public-access communication networks. ASC X12 believes that all sizes of companies using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties incurred from each organization using its own formats to transact business. Within ASC X12, the various subcommittees are responsible for developing standards in their area of expertise. Once a subcommittee has developed a draft standard the full ASC X12 membership reviews and approves it according to the operating policies and procedures. All standards (new or changed) require the consensus approval of the full ASC X12 membership. The approved standard becomes a draft standard for trial use for a reasonable trial period. After the trial period the draft standards are submitted to ANSI to become an American National Standard (ANS).

ASC X12 Patient Information (275)

Contact for more information: Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standard;

A) The objective of the Patient Information (275) is to support the exchange of demographic, clinical and other supporting patient information to support administrative reimbursement processing as it relates to the submission of health care claims for both health care products and services.

B) This transaction set can be used to communicate individual patient information requests and patient information (either solicited or unsolicited) between separate health care entities in a variety of settings to be consistent with confidentiality and use requirements.

C)This transaction is used to provide additional patient information to support administrative reimbursement for health care products and services.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has be developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard:

A) The Patient Information (275) is not a guideline. However the X12 Insurance Subcommittee is currently developing implementation guides.

B)The Patient Information (275) standard is fully implementable. The transaction set was approved as a Draft Standard for Trial Use (DSTU) in June of 1995 as Version 0030?2.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)This standard does not require an implementation guide. ASC X12 has published four Type II Tutorial reports or tutorials for version 003041 in October of 1994, version 003050 in October 1995, version 003051 in February 1996, and version 003060 in April of 1996. To facilitate consistent implementation across the health care industry, the X12 Insurance Subcommittee is currently in the process of completing five implementation guides for version 003070 encompassing medical, hospital, dental, pharmaceutical claims, and workers compensation jurisdictional reporting with an anticipating publication date of April 1997.

E)There currently is only one implementation guide for the Patient Information (275) transaction.

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance:

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

C)Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards as costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity:

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D) ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships with other standards:

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

A) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

B)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

C)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

IEEE 1157 MEDIX Project

Institute of Electrical and Electronics Engineers, Medical Information Bus (MIB) General

Committee

ANSI Accreditation:

IEEE is a charter member of ANSI and is an Accredited Standards Developing Organization.

IEEE 1073, Standard for Medical Device Communications

A family of documents that defines the entire seven layer communications requirements for the "Medical Information Bus" (MIB). This is a robust, reliable communication service designed for Intensive Care Unit, Operating Room, and Emergency Room bedside devices.

Approved Standards:

1) IEEE 1073.3.1 - Standard for Medical Device Communications, Transport Profile - Connection Mode: This document defines the services and requirements for a bedside subnetwork. It defines services similar to those defined in Ethernet and TCP/IP. Combined

with 1073.4.1, it defines the hardware required to offer hospitals to ensure ease of use for clinician initiated automatic data capture from bedside devices. An approved ANSI Standard since August, 1995.

2) IEEE 1073.4.1 - Standard for Medical Device Communications, Physical Layer, Cable Connected: This document defines the cables, connectors, data rates, and bit level encoding for the MIB. It is coupled with IEEE 1073.3.1 to complete the "lower layers" for 1073. An approved ANSI Standard since August, 1995.

3) IEEE 1073 - Standard for Medical Device Communications, Overview and Framework:

This document serves as an overview of the 1073 family of standards and a roadmap of which

documents, present and planned, contain information on different facets of communication. It defines the underlying philosophy in the 1073 family of standards. Approved by the IEEE Standards Board in March, 1996.

On-going Standards Work:

• IEEE 1073.1 - Standard for Medical Device Communications, Medical Device Data Language (MDDL) Overview and Framework: This document defines the ISO Standards and conventions for using Object-Oriented Technology to define communications services for bedside medical devices. This is expected to go to ballot in late 1996.
• IEEE 1073.1.1 - Standard for Medical Device Communications, MDDL Common Definitions: This document defines the common definitions for the object oriented communications services for medical devices.
• IEEE 1073.1.2 - Standard for Medical Device Communications, MDDL Virtual Medical Device, Generalized: This document defines the general features of all virtual medical devices, in an object oriented environment. This is highly harmonized with CEN TC251, PT021 First Working Draft "Vital Signs Representations".
• IEEE 1073.1.3 - Standard for Medical Device Communications, MDDL Virtual Medical Device, Specialized: This document defines the general features of specialized virtual medical devices for specific device categories. This is highly harmonized with CEN TC251, PT021 First Working Draft "Vital Signs Representation".
• IEEE 1073.1.3.1 - Standard for Medical Device Communications, MDDL Virtual Medical Device, Specialized, Infusion Device: Defines the specific object oriented communications services for infusion devices. This project should have a first draft by the end of 1996.
• IEEE 1073.1.3.2 - Standard for Medical Device Communications, MDDL Virtual Medical Device, Specialized, Vital Signs Monitor: Defines the specific object oriented communications services for vital signs monitors.
• IEEE 1073.1.3.1 - Standard for Medical Device Communications, MDDL Virtual Medical Device, Specialized, Ventilator: Defines the specific object oriented communications services for ventilators. This project was started in April, 1996.
• IEEE 1073.2 - Standard for Medical Device Communications, Application Profile, Overview and Framework: Describes the common theory and rules for all application profiles to be defined for the 1073 family. This was approved by the ballot group in late 1995, but is in editing stage. Should be approved by IEEE Standards Board in September, 1996.
• IEEE 1073.2.0 - Standard for Medical Device Communications, Application Profile, Medical Device Encoding Rules: An optimization of ISO Basic Encoding Rules made for bedside medical devices. This should go to ballot in late 1996.
• IEEE 1073.2.1 - Standard for Medical Device Communications, Application Profile, Minimum Set: Defines the minimum application profile for bedside medical devices. The service provided allows for one way capture of device data. This should go to ballot in late 1996.
• IEEE 1073.2.2 - Standard for Medical Device Communications, Application Profile, Basic Capabilities: Defines the basic set of communications services for an application profile for bedside medical devices. The services provided allow for two way getting and setting of attribute values, and for creating and deleting of objects.

Contact For More Information:

Bob Kennelly

Chair, IEEE 1073 General Committee

LinkTech

30 Orville Drive

Bohemia, NY 11716

(P) 516-567-5656, ext. 7482

(F) 516-563-2819

(E) bobk@linktech.ilcddc.com

Description of Standard:

The IEEE 1073 Family of Standards serves to achieve the following: Objectives: To standardize data communications for patient connected bedside devices, optimized for the acute care setting, to allow clinicians to set up device communications in a "plug and play" fashion.

Functions:

The function of this family of standards is to permit real time,

continuous, and comprehensive capture of device data from patient connected bedside devices. This data includes physiological parameter measurements and device settings.

User Environment:

This family of standards is used in any setting containing patient connected bedside devices, but was optimized in its design for acute care settings such as intensive care, operating rooms, and emergency rooms.

Systems Environment:

IEEE 1073 defines a bedside sub-network where devices communicate with a bedside communications controller. The standard is strongly based on ISO Open Systems Interconnect, and as such is able to be compatible with most computer industry standard implementations. Prototype implementations have been done with DOS, Windows, Windows NT, TCP/IP and Ethernet.

Application Function/Domain Completeness:

The lower layers, or hardware, for this standard is completed as an IEEE and ANSI Standard. Drafts exist for many of the upper layer pieces required to do prototyping. Several documents are going to ballot in 1997.

In what way(s) is this standard superior to other standards in this category/classification?

The IEEE 1073 is the first attempt to standardize device interfaces. The previous data interfaces provided by device manufacturers were based on RS-232, in which only the very basic voltage levels and data rates are defined. Each device manufacturer needed to invent heir own language for device communications. Device manufacturers frequently changed this language in large and small ways across product lines and product revisions. The result was an entirely impossible quagmire of differing device interfaces for devices that tend to be portable and able to plug into multiple ports, each requiring a specific device driver to talk. It is similar to needed a different phone plug for each area code you want to call.

Readiness of Standard:

A) The IEEE 1073 family of standards are design standards that must be implemented during device design, or in after market converters. The implementation of 1073 allows for comprehensive, automatic collection of device data, which will affect clinician practice.

B)IEEE 1073 is presently implementable, and is in the process of being done at McKay-Dee Hospital in Ogden, Utah. The lower layers standards are supported by commercially available silicon and boards. The upper layers exist as drafts, using available object oriented models. To implement 1073 in 1996, a hospital must know its device type population, and design tables in their HIS to interpret the specific message structure, format, and content from their medical devices. The delivery of this message is standardized today.

C)The IEEE 1073 Standards are available from IEEE by calling 908-562-3800.

D)There is presently no implementation guide for the IEEE 1073 Standards.

E)There is presently no implementation guide for the IEEE 1073 Standards.

F)A conformance test plan and method is intended future work of the IEEE 1073 General Committee.

G)There are no conformance test tools available for IEEE 1073.

H)There are no conformance test tools available for IEEE 1073.

I)The lower layers of the standard are completed and implementable today. The lower layers are analogous to using ethernet and TCP/IP. The upper layers are still being developed, with several documents expected to be approved in 1997.

J)There are no extensions being developed, since the scope for this standard includes all communication layers for bedside medical devices.

AA) Ballot groups for 5 upper layer documents are being formed and will be closed by the end of 1996. Balloting for these documents will occur in the second quarter of 1997, with approval by the IEEE Standards Board in September or December 1997.

BB) Upon approval of the documents in 1997, a full implementation of IEEE 1073 will be achievable. Prototype implementations will be done in the first half of 1997.

Indicator of Market Acceptance:

A)As of January 1996, approximately 400 copies of the approved standards had been sold by IEEE.

B)IEEE 1073 is in the early adopter stage in the market. There are people at LDS Hospital, Univ. of West Virginia, Univ. Texas Houston Medical School, Texas Children's Hospital, and Naval Hospital San Diego doing prototyping work. One medical device vendor, Siemens, is shipping product in Europe with IEEE 1073 embedded.

C)There is prototype and evaluation work on IEEE 1073 being done in UK, Germany, Spain, Norway, and Japan.

D)There is growing demand for 1073 from US Hospitals, which is being recognized by US device vendors, and being considered for their new product designs. Also, the Hewlet-Packard led Andover Working Group has stated their intent to do prototype implementations of 1073 in 1997.

Level of Specificity:

Notes:

A) IEEE 1073 is a family of standards that describe in specific detail what needs to be implemented to be compliant.

B)The lower layers of 1073 are very specifically defined and are supported by a commercially available integrated circuit product. The upper layer drafts define very specific message contents and structure for specific types of bedside medical devices.

C)IEEE 1073 references many ISO communications standards to define the communications protocol. These include ISO Standards for RS-485, HDLC, Basic Encoding Rules, ASN.1, and the Guide to Developing Managed Objects.

D)There is a defined nomenclature within IEEE 1073 that defines the parameter name and a code structure for physiologic parameters and device settings.

E)The code set is a subset of the Medical Device Data Language (MDDL), and is listed as the MDDL Nomenclature, IEEE 1073.1.1

F)IEEE 1073.1.1 is a draft available from IEEE. It has also been submitted to LOINC for inclusion in that work.

G)There is presently no users' guide for the code set. However, one of the vendor members of the general committee has developed a tool in-house that may be released for public use in 1997.

H)The IEEE 1073 nomenclature is not presently being used in any commercial application.

I)IEEE 1073.1.1 should be balloted in 1997.

Relationships With Other Standards:

A)IEEE 1073 is a bedside subnetwork that collects device data. In any application that requires this data, 1073 has a relationship with that standard. The relationship will most likely be expressed through application gateways. Such examples may include: conversion of device data to HL7 format for inclusion of device parameters in an HL7 based clinical data depository; conversion of device data into an X12 message for inclusion in billing applications; use of device data by an electronic medical record standardized any other SDO.

B)IEEE 1073 has been having its meeting in conjunction with the HL7 working group meetings to ensure rapid convergence of ideas.

C)The most important aspect of our coordination efforts is elimination of workscope overlap. For example, at the last HL7 meeting we received a presentation on LOINC that resulted in formal submittal of our work to LOINC.

D)The only assumed condition we have is that our work will be viewed as valuable and taken as a contribution.

IEEE 1073 is entirely based on the ISO Open System Interconnect model and multiple ISO communications standards such as HDLC, BER, ASN.1, MOSI, GDMO.

E)The remaining gaps are mainly in areas of implementations to ensure that the goals of standardization are achievable in actual practice.

F)The nearest term efforts on implementations will be done in the Andover Working Group.

Identifiable Costs:

• Please indicate the cost or your best estimate for the following:
• Cost of licensure: There is no licensure cost for IEEE 1073.
• Cost of acquisition : Medical device with embedded IEEE 1073 interfaces should have minimal cost difference from present purchase prices. The hospital infrastructure to support
• bedside data capture will likely be similar to the costs of putting PC's at bedsides.
• Cost/timeframes for education and training: Unknown
• Cost/timeframes for implementation: Unknown

Please note any other cost considerations: The probable investment in IEEE 1073 infrastructure for hospitals will be small compared to the benefits from being able to have comprehensive data on the conditions of the most gravely ill, and costly, patients.

Digital Imaging Communication in Medicine (DICOM) Standards Committee

Membership: Professional specialty societies, industry (National Electrical Manufacturers Association and other industry), and government, industry, and trade association liaison members.

ANSI Accreditation:

NEMA is an ANSI-Accredited standards developing organization. The DICOM Standards Committee, through NEMA, can develop American National Standards via the ANSI Canvass Procedure. The DICOM Standards Committee is considering applying for ANSI Accredited Standards Committee status in 1997.

DICOM Standard. NEMA PS3.x - 1992, 1993, 1995

Contact For More Information

DICOM Secretariat: NEMA

Mr. David Snavely, 1300 North 17th Street, Suite 1847, Rosslyn, VA 22209

e-mail: dav_snavely@nema.org

DICOM Liaison Working Group Secretariat: American College of Radiology

Mr. James Potter, 1891 Preston White Drive, Reston, VA 22091

e-mail: jamesp@acr.org

DICOM Structured Reporting Secretariat: College of American Pathologists

Ms. Karen Kudla, 325 Waukegan Road, Northfield, IL 60093-2750

e-mail: kkudla@cap.org

DICOM Visible Light Working Group Secretariat: Am. Soc. of Gastro. Endoscopy

Dr. Louis Korman, Washington VA Medical Center

e-mail: lkorman@erols.com

DICOM ANSI HISB Liaison: W. Dean Bidgood, Jr., M.D., M.S.

Box 3321, Duke University Medical Center, Durham, NC 27710

e-mail: bidgood@nlm.nih.gov

Description of Standard

DICOM specifies a generic digital format and a transfer protocol for biomedical images and image-related information. The specification is usable on any type of computer and is useable to transfer images over the Internet. DICOM interfaces are available for nearly all types of imaging devices sold by all of the leading vendors of radiology imaging equipment. DICOM is now being adopted for use outside of radiology (for example, in pathology, internal medicine, veterinary medicine, and dentistry).

The most commonly used diagnostic and therapeutic biomedical image types are fully covered by DICOM. DICOM has been adopted by the U.S. Veterans Affairs Administration and the U.S. Armed Forces.

DICOM enables interchange of text information, coded information, measurements, images, and other binary data. The systems domain focus is on all aspects of image management. Interfacing with other text-based information systems is also specified. Trial implementation of a new structured report interface will begin in January, 1997.

Readiness of Standard

All radiology image specifications of DICOM are fully implementable. The visible light (color) image types and the structured reporting interfaces will be available for trial implementation in January, 1997. Additional draft specifications for radiation oncology, PostScript™ Print management, Positron Emission Tomography, image data compression, security, image presentation (standardized display) parameters are under development at the time of this writing.

DICOM is an implementable standard. There is no official implementation guide. Public domain software implementations are available on the Internet. Several companies offer implementation software "tool kits" for sale. Further information about DICOM resources may be obtained on the NEMA WWW site: (http://www.nema.org).

Indicator of Market Acceptance

DICOM is the dominant non-prominent data interchange message standard in biomedical imaging. All major radiology equipment vendors have implemented the standard. Acceptance is growing rapidly outside of radiology. Interconnectivity among many vendors has been demonstrated to the public in many international meetings since 1992.

Level of Specificity

DICOM is a highly specific and explicit specification. The standard specifies all data interchange parameters from hardware factors (industry standards adopted) up through the bit/byte stream, services, protocols, to the domain knowledge layer. A very practical and useful level of interoperability can be achieved with the standard. The need for local configuration agreements is minimized. The SNOMED DICOM Microglossary™ is the preferred coding system -to- message data element Mapping Resource. SNOMED (Systematized Nomenclature of Human and Veterinary Medicine, © College of American Pathologists) and LOINC (Logical Observation Identifiers, Names, and Codes) database are the preferred coding systems. DICOM also supports locally-defined (or private) coding systems.

Relationships With Other Standards

DICOM has a close relationship to the HL7 Standard in the area of Imaging System - Information System interfacing. DICOM has entered into standards developing partnership with the SNOMED Authority of the College of American Pathologists. Ultrasound, cardiovascular, and other DICOM measurement codes are being developed in close cooperation with the LOINC Committee. Internationally, DICOM is compatible with the CEN/TC 251 WG4 MEDICOM Standard and the Japanese JIRA and MEDIS-DC Standards for network interchange of images and image-related information.

Enhancement of the Information System - Imaging System interface specifications of DICOM and related standards is underway at the time of this writing. DICOM offers advanced capabilities for management of binary data objects (such as images) that are not available in the current versions text-based data interchange standards (HL7 and X-12).

Identifiable Costs

The printed specification of the DICOM Standard is available from NEMA for approximately $300. Implementation training is available from private consulting and training companies. Due to the complexity of imaging technology, the DICOM specification is complex. Significant training is required in order to write compatible software. However, the availability of software implementation "tool kits" from several commercial sources has greatly simplified the implementation of DICOM for most vendors.

ASTM Committee E31 on Healthcare Informatics

The category/classification of this standard is: Data Content Vocabulary for Computer-Based Patient Records

The standards development organization is ASTM. ASTM is an ANSI accredited standards development organization.

Organized in 1898, ASTM (the American Society for Testing and Materials) has grown into one of the largest voluntary standards development systems in the world. ASTM is a not-for profit organization that provides a forum for producers, users, ultimate consumers, and those having a general interest (representatives of government and academia) to meet on common ground and write standards for materials, products, systems, and services. From the work of 132 standards-writing committees, ASTM publishes more that 9000 standards. ASTM headquarters has no technical research or testing facilities; such work is done voluntarily by 35,000 technically qualified ASTM members located throughout the world. ASTM provides continuing education and training in the use and application of ASTM standards through Technical and Professional Training courses. In 1987, ASTM formed the Institute for Standards and Research (ISR). The purpose of the Institute is to provide a mechanism for conducting research to improve the quality and timeliness of ASTM standards. It does no research, but serves as the intermediary between the standards-writing community and the public or private agencies that could provide appropriate research and technical services, or supply funding for such research.

Accreditation

ASTM is an ANSI Accredited by the Organization Method. All ASTM Committee E31 standards are approved as American National Standards

ASTM E1384-96 Standard Guide for Content and Structure of the Computer-Based Patient Record

Contact: Manager - Committee E31, ASTM

100 Barr Harbor Drive

West Conshohocken, PA 19373

Ph: 610-832-9500

Fax: 610-832-9666

Standard Description

This standard guide is intended to provide the framework vocabulary for the computer-based patient record content. It proposes a minimum essential content drawn from a developing annex of dictionary elements.

Elements are populated using master tables which range from standard code systems to reference tables harmonized with HL-7 Version 2.2. It calls for unique data views specified

for clinical settings. The standard contains an annex of dictionary items intended as a reference standard for designers and developers.

Functions: Implementation Independent Content Organization

Master Tables

Data Views

User Environment: Administrative And Clinical Users

Software Developers - Data Base Design

Educators - Health Informatics

Systems Environment: Does Not Specify System Environment

Evolving Standard - Ongoing Development

Most Complete CPR Content Standard

Value

There are no other standards that address the overall content vocabulary for computer-based patient records. This standard offers an initial data model intended for application in all healthcare settings. It currently serves as a reference model for vendors and institutions working to build data base content for CPRs.

Readiness of the Standard

A) This standard is a guideline that addresses policy and design. Since it offers an overall data model, users would incorporate the elements of the standard that apply to their situation. For example, requests for this standard come from designers working on the data content of the CPR. The proposed content is being used as a base data model and for data definitions.

B)This standard does not require a separate implementation guide. It should be used in conjunction with the Standard Specification for Coded Values for the Computer-Based Patient Record E1633 to achieve more specificity. Vocabulary data elements are defined in E1384, which include limited code values and pointers to E1633 for the specific master tables and code systems and values needed for the data elements. Code sets are assumed, referenced in E1633 for data elements; and harmonized with code sets in HL-7 where feasible.

C)How can the standard be obtained? ASTM standards are available through the ASTM Customer Service Department by calling 610-832-9585. Standards can also be ordered through the ASTM Web Site at www. astm.org

The standard is fully usable now as a reference guide for designers/developers of Computer-Based Patient Records.

Milestones

Milestones identified are additional content, harmonization with companion standards and joint development work on new vocabulary. The most recent ballot was in l996. Proposed revisions are already in development and updates will be balloted in l997.

Indicator Of Market Acceptance

A)If the standard is a guideline, how many copies have been requested and distributed? Approximately 2300 copies of the E31 standards have been distributed.

B)If the standard is an implementable standard, how many vendors, healthcare organizations, and/or government agencies are using it?

This type of information is difficult to obtain for the E31 standards. It is indicated where available under the document specific information to follow.

This standard is included in the ASTM l996 Book of standards made available to people who join ASTM. Currently, the membership of E31 Committee on Healthcare Informatics is over 300. Actual numbers of interested individuals who have requested this standard far exceeds the membership.

The Veterans Administration reports using this as a reference standard.

Other indicators of market acceptance include users who are currently involved in developing CPR applications within individual hospitals and hospital consortiums; vendors who are working on CPR data repository models; and CPR project planners who are in the process of defining content standards for their enterprise.

This standard is also included in a l996 publication that has been adopted by all Health Information Administration programs in the United States.

Level of Specificity

This standard is a guide. It calls for standard content expressed in a uniform manner. It does not provide data dictionary specificity. It identifies the common information framework that is part of patient records in multiple settings.

Relationship With Other Standards

As indicated, this standard depends on ASTM E1633 for specified coded values; uses some HL-7 data elements and a limited number of master tables. Ongoing analysis is performed to continue work on harmonizing elements with collaborative work, e.g. the Minimum Data Set from the National Committee on Vital and Health Statistics. Harmonization with message standards are proposed for revisions where possible. Functionality will be strengthened by coordination. Conditions assumed for coordination to be effective include joint work initiatives among standards developers and representatives from the user community who currently use this standard.

E1384 can be obtained from ASTM at:

100 Barr Harbor Drive, West Conshohocken, PA 19428

(610) 832-9500 Web Site: http://www.astm.org

Category/Classification Of The Standard

Health Claim Attachments

ASTM E1769-95 Standard Guide for Properties of Electronic Health Records and Record Systems

Contact For More Information

Manager - Committee E31, ASTM

100 Barr Harbor Drive

West Conshohocken, PA 19373

Ph: 610-832-9500

Fax: 610-832-9666

Description Of Standard

This standard defines the requirements, properties, and attributes of a computer-based patient record. It serves as an agreement among all the parties about the goals and constraints of the computer-based patient record, and provides criteria for making tradeoffs and decisions about how the record will be configured. The guide defines a computer-based record as the structured set of demographic, environmental, social, financial, and clinical data elements in electronic form needed to document the healthcare given to a single patient. It discusses how information is entered, dealing with such questions as who can enter, how is information identified, how is it validated, and who is accountable. It describes data attributes, such as permanence, accessibility, reliability, internal consistency, and security. System response time and the ability to process data are considered. Output criteria are addressed, including who can access information, the level of fact detail available, customization of display, multimedia outputs, and export to other systems. The system must protect the rights of the patient to confidentiality and the rights of the care provider to privacy. The concept of connecting together various encounter records of a patient to produce a longitudinal patient record is described. Systems to implement computer-based medical records must support local clinical functions. In addition, they should also be considered nodes of a national clinical network. The data content of the records must meet the needs of all legitimate users, such as payers, regulatory agencies, public health workers, researchers, and quality of care/outcome studies personnel. The records must be mobile and accessible to all authorized users. This ensures easy transport of records when patients move or change care providers. It also permits the extraction of billing, monitoring, and research data into other computer systems. Full logical compatibility among data banks is essential for these purposes.

Readiness Of Standard

The standard is published and is an American National Standard. How can the standard be obtained? ASTM standards are available through the ASTM Customer Service Department by calling 610-832-9585. Standards can also be ordered through the ASTM Web Site at www. astm.org

Indicators Of Market Acceptance

Approximately 2300 copies of the E31 standards have been distributed.

A wide variety of vendors are implementing EHR systems. The standard describes many of the features which are being incorporated into these systems and includes many features which have yet to be implemented by vendors. There has been no feedback to the standards committee from vendors indicating any objection to the features described in the standard other than the technical difficulty of achieving some of the functions described therein.

Level Of Specificity

The standard describes EHR functions at a functional level. It makes no attempt to recommend a specific implementation strategy but rather attempts to outline how the various functions described can interact to provide a functional EHR.

Relationship With Other Standards

Related ASTM standards, notably E 1384, provide information on topics such as the data elements which should be included in an EHR system. Numerous additional standards such as HL7 for data exchange and various coding schemes to determine data content are also relevant.

Identifiable Costs

The cost to implement this standard depends heavily on the technology and methodologies chosen by a specific vendor.

Category/Classification Of The Standard

Health Claim Attachments

ASTM E1633-95 Standard Specification for Coded Values Used in the Computer-Based Patient Record

Contact For More Information

Manager - Committee E31, ASTM

100 Barr Harbor Drive

West Conshohocken, PA 19373

Ph: 610-832-9500

Fax: 610-832-9666

Description Of Standard

This specification identifies the lexicons to be used for the data elements identified in the Annex portion of Standard E1384, Guide for the Content and Structure of the Computer-Based Patient Record. It is intended to unify the representations for (1) the identified data elements for the computer-based patient record, (2) data elements contained in other standard statistical data standards, (3) data elements used in other healthcare data message exchange format standards, or (4) in data gathering forms for this purpose, and (5) in data derived from these elements so that data recorded in the course of patient care can be exchangeable and provide consistent devel0pment of CPR content vocabulary that can also provide an accurate source for statistical and resource management data. Code values are specified using master tables which range from standard code value sets identified directly for the data element to standard code systems such as ICD9 to reference tables harmonized with HL7 Version 2.2. It promotes consistent data views specified for clinical settings. The standard is intended as a reference standard for designers and developers.

Functions: Implementation independent content organization

Identifies data representation for vocabulary elements

Includes an initial catalog of coded value sets

References known mater tables

User Environment: Administrative and clinical users

Software developers - data base design

Educators - health informatics

Systems Environment: Does not specify system environment

Evolving standard - ongoing development is focused on alignment with value sets used in companion standards

Value: Provides the 2nd edition of detailed representation for the listed data

elements contained in the vocabulary content in Standard ASTM E1384. It currently serves as a reference model for vendors and institutions working to build data base content for CPRs.

Readiness Of Standard

This standard is a specification that addresses data structure and data dictionary design. Since it combines with E1384 to offer an overall data model, users would incorporate the elements of the standard that apply to their situation. Requests for this standard come from designers working on the data content of the CPR. The proposed content is being used as a base data model and for data definitions.

This standard does not require a separate implementation guide. It should be used in conjunction with the Standard E1384. Vocabulary data elements are defined in E1384, which include limited code values and point to this specification for the specific delineations for the data form, coded values to be used in representing the element and where appropriate, and more formally identified master tables and code systems needed for the data elements. Code sets are assumed, referenced in E1633 for data elements and harmonized with code sets is ASTM Standards E 1238, E1239 and HL7 where feasible.

The standard is fully usable now as a reference guide for designers/developers of computer-based patient records.

Milestones identified are continued code value expansions, harmonization with companion standards and joint development work on new vocabulary. The most recent ballot was 1996. Proposed revisions and updates will be balloted in early 1997.

The standard is published and is an American National Standard. How can the standard be obtained? ASTM standards are available through the ASTM Customer Service Department by calling 610-832-9585. Standards can also be ordered through the ASTM Web Site at www. astm.org

Indicators Of Market Acceptance

Approximately 2300 copies of the E31 standards have been distributed.

The Veterans Administration reports using this as a reference standard. Other indicators include users who are currently involved in developing CPR applications within individual hospitals and hospital consortiums; vendors who are working on CPR data repository models; and CPR project planners who are in the process of defining content standards for their enterprise.

This standard is also included in a 1996 publication that has been adopted by all Health Information Administration programs in the United States. Another text due out in 1997 on data dictionaries for healthcare recommends usage of this specification in conjunction with E1384 for constructing data dictionaries in healthcare organizations.

Level Of Specificity

This standard calls for content to be expressed in a uniform manner. It does provide some data dictionary specificity. It identifies the common representation for data to be part of computer-based patient records in multiple settings.

Relationship With Other Standards

As indicated, this standard is written to provide the detailed specificity to ASTM E1384 for specified code values. Major work on this standard continues to be comparison and reconciliation with other standards and evolving data sets such as the Minimum Data Set from the National Committee on Vital and Health Statistics; and the National Provider Identification efforts underway in the Health Care Financing Administration. Harmonization with message standards and data element values included in X12 are proposed for revisions where possible. Functionality will be strengthened by coordination. Conditions assumed for coordination to be effective include joint work initiatives among standard developers and representatives from the user community who currently use this standard.

Enrollment and Disenrollment in a Health Plan

Accredited Standards Committee (ASC) X12, Health Care Task Group

ASC X12 Benefit Enrollment and Maintenance (834)

Contact for more information - Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standard

A) The objective of the - Benefit Enrollment and Maintenance (834) is to support the administration of enrollment and disenrollment of covered individuals within various insurance products.

B) This transaction set can be used to enroll and disenroll covered individuals for insurance products such as health, life, flexible spending accounts, and retirement products.

C)This transaction is used for administration of insurance benefit plans.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has be developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard

A) The Benefit Enrollment and Maintenance (834) is not a guideline. However X12 has published implementation guides.

B)The Benefit Enrollment and Maintenance (834) standard is fully implementable. The transaction set was approved as a Draft Standard for Trial Use (DSTU) in February of 1992 as Version 003021.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)Each X12 transaction must have an implementation guide and a complete and unambiguous data dictionary if identical implementations are to be obtained. The X12 began writing implementations guides during calendar year 1996 for version 3070. None have yet been tested between operating trading partners. No draft data dictionary is yet available.

E)There is only one implementation guide for the Benefit Enrollment and Maintenance (834).

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

C)Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards as costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

G) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

H)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

I)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

National Council for Prescription Drug Programs (NCPDP)

NCPDP Member Enrollment Standard

NCPDP recommends the use of a standardized format for member enrollment among insurance carriers, third-party administrators, and other providers. The Member Enrollment Standard was developed to enhance the enrollment verification process and provide a consistent format for enrollment verification processing.

Eligibility for a Health Plan

Accredited Standards Committee X12 Insurance Subcommittee, Health Care Task Group

ANSI Accreditation: X12 was accredited as an ANSI accredited standards committee in 1979. Subsequent X12 procedure changes have required ANSI re-accreditation which was last granted in 1987.

The main objective of ASC X12 is to develop Electronic Data Interchange (EDI) standards to facilitate electronic business transactions (i.e. order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions). ASC X12 endeavors to structure standards in a manner that computer programs can translate data to and from internal formats without extensive reprogramming.

This strategy allows companies to maximize their resources required for internally developed or commercial software (recommended) and private or public-access communication networks. ASC X12 believes that all sizes of companies using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties incurred from each organization using its own formats to transact business. Within ASC X12, the various subcommittees are responsible for developing standards in their area of expertise. Once a subcommittee has developed a draft standard the full ASC X12 membership reviews and approves it according to the operating policies and procedures. All standards (new or changed) require the consensus approval of the full ASC X12 membership. The approved standard becomes a draft standard for trial use for a reasonable trial period. After the trial period the draft standards are submitted to ANSI to become an American National Standard (ANS).

ASC X12, Health Care Eligibility/Benefit Inquiry (270)

ASC X12, Health Care Eligibility/Benefit Information (271)

Contact For More Information: Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standard:

A) The objective of the Health Care Eligibility/Benefit Inquiry (270) - Health Care Eligibility/Benefit Information (271) is to provide for the exchange of eligibility inquiry and response to individuals within a health plan.

This transaction set can be used by health care providers to request and receive coverage and payment information on the member/insured in a batch environment where real time processing is not required.

B)This transaction is used to provide additional patient eligibility information to support administrative reimbursement for health care products and services.

C)This standard may be used from any operating system, network, or hardware platform.

D)The standard has be developed with widespread input from the health care industry incorporating all business needs into its functionality.

E)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

F)Standards. These standards are developed using a consensus process by the users in the health care industry.

G)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard:

A) The Health Care Eligibility/Benefit Inquiry (270) - Health Care Eligibility/Benefit Information (271) is not a guideline. However the X12 Insurance Subcommittee is currently developing implementation guides.

B)The Health Care Eligibility/Benefit Inquiry (270) - Health Care Eligibility/Benefit Information (271) standard is fully implementable. The transaction set was approved as a Draft Standard for Trial Use (DSTU) in February of 1993 as Version 003031.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)This standard does not require an implementation guide. ASC X12 has published four Type II Tutorial reports or tutorials for version 003041 in October of 1994, version 003050 in October 1995, version 003051 in February 1996, and version 003060 in April of 1996. To facilitate consistent implementation across the health care industry, the X12 Insurance Subcommittee is currently in the process of completing five implementation guides for version 003070 encompassing medical, hospital, dental, pharmaceutical claims, and workers compensation jurisdictional reporting with an anticipating publication date of April 1997.

E)There currently is only one implementation guide for the Health Care Eligibility/Benefit Inquiry (270) - Health Care Eligibility/Benefit Information (271) transaction.

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance:

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Every Medicare carrier and intermediary has implemented ASC X12 standards for healthcare eligibility. All carriers have implemented the 270/271 for eligibility. Many other payers have followed HCFA's lead and implemented the standard as well.

C)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

D)Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards as costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity:

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards:

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

G) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

H)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

I)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

ASC X12, Health Care Task Group

Interactive Health Care Eligibility/Benefit Inquiry (IHCEBI)

Interactive Health Care Eligibility/Benefit Response (IHCEBR)

Contact For More Information: Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standard:

A) The objective of the Interactive Health Care Eligibility/Benefit Inquiry (IHCEBI) - Interactive Health Care Eligibility/Benefit Response (IHCEBR) is to provide for the exchange of eligibility inquiry and response to individuals within a health plan.

B) This interactive message can be used by health care providers to request and receive coverage and payment information on the member/insured in an online real time environment.

C)This message is used to provide additional patient eligibility information to support administrative reimbursement for health care products and services.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has be developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard

A) The Interactive Health Care Eligibility/Benefit Inquiry (IHCEBI) - Interactive Health Care Eligibility/Benefit Response (IHCEBR) is not a guideline. However the X12 Insurance Subcommittee is currently developing implementation guides.

B)The Interactive Health Care Eligibility/Benefit Inquiry (IHCEBI) - Interactive Health Care Eligibility/Benefit Response (IHCEBR) standard is fully implementable. The message was approved as a Draft Standard for Trial Use (DSTU) in October of 1994 as Version 003050.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)Each X12 transaction must have an implementation guide and a complete and unambiguous data dictionary if identical implementations are to be obtained. The X12 began writing implementations guides during calendar year 1996 for version 3070. None have yet been tested between operating trading partners. No draft data dictionary is yet available.

E)There currently is only one implementation guide for the Interactive Health Care Eligibility/Benefit Inquiry (IHCEBI) - Interactive Health Care Eligibility/Benefit Response (IHCEBR).

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator Of Market Acceptance

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Every Medicare carrier and intermediary has implemented ASC X12 standards for payment and remittance advice. Many other payers have followed HCFA's lead and implemented the standard as well.

C)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

D)Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards as costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

G) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

H)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

Health Care Payment and Remittance Advice

Accredited Standards Committee X12 Insurance Subcommittee, Health Care Task Group

ANSI Accreditation: X12 was accredited as an ANSI accredited standards committee in 1979. Subsequent X12 procedure changes have required ANSI re-accreditation which was last granted in 1987.

The main objective of ASC X12 is to develop Electronic Data Interchange (EDI) standards to facilitate electronic business transactions (i.e. order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions). ASC X12 endeavors to structure standards in a manner that computer programs can translate data to and from internal formats without extensive reprogramming.

This strategy allows companies to maximize their resources required for internally developed or commercial software (recommended) and private or public-access communication networks. ASC X12 believes that all sizes of companies using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties incurred from each organization using its own formats to transact business. Within ASC X12, the various subcommittees are responsible for developing standards in their area of expertise. Once a subcommittee has developed a draft standard the full ASC X12 membership reviews and approves it according to the operating policies and procedures. All standards (new or changed) require the consensus approval of the full ASC X12 membership. The approved standard becomes a draft standard for trial use for a reasonable trial period. After the trial period the draft standards are submitted to ANSI to become an American National Standard (ANS).

ASC X12N Health Care Claim Payment/Advice (835).

Contact For More Information: Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standard:

A) The objective of the Health Care Claim Payment/Advice (835) is to support reimbursement processing for health care products and services.

B) This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution.

C)This transaction is used for administrative reimbursement for health care products and services.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has be developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard

A) The Health Care Claim Payment/Advice (835) is not a guideline. However X12 has published implementation guides.

B)The Health Care Claim Payment/Advice (835) standard is fully implementable.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)This standard does not require an implementation guide. ASC X12 has published four Type II Tutorial reports or tutorials for version 003041 in October of 1994, version 003050 in October 1995, version 003051 in February 1996, and version 003060 in April of 1996. To facilitate consistent implementation across the health care industry, the X12 Insurance Subcommittee is currently in the process of completing five implementation guides for version 003070 encompassing medical, hospital, dental, pharmaceutical claims, and workers compensation jurisdictional reporting with an anticipating publication date of April 1997.

E)There are currently two versions of the implementation guide for the Health Care Claim Payment/Advice (835) one for version 003051 and one for version 003070.

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Every Medicare carrier and intermediary has implemented ASC X12 standards for claim and remittance advice. All carriers have implemented the 270/271 for eligibility. Many other payers have followed HCFA's lead and implemented the standard as well.

C)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

D)Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards as costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

G) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

H)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

I)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

Health Care Premium Payments

Accredited Standards Committee X12 Insurance Subcommittee, Health Care Task Group

Consolidated Service Invoice/Statement (811)

Payment Order/Remittance Advice (820)

Contact For More Information: Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standard:

A) The objective of the Consolidated Service Invoice/Statement (811) - Payment Order/Remittance Advice (820) is to facilitate health plan premium billing and payment.

B)These transaction sets can be used by health care prayers and plan sponsors for the purpose of premium billing (Consolidated Service Invoice/Statement 811) and collection (Order/Remittance Advice 820).

C)These transactions are used for the administrative reimbursement for health plans between health care payers and plan sponsors.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has be developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard:

A) The Consolidated Service Invoice/Statement (811) - Payment Order/Remittance Advice (820) is not a guideline. However the X12 Insurance Subcommittee is currently developing implementation guides.

B)The Consolidated Service Invoice/Statement (811) - Payment Order/Remittance Advice (820) standard is fully implementable. The transaction has been approved as a Draft Standard for Trial Use (DSTU).

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)Each X12 transaction must have an implementation guide and a complete and unambiguous data dictionary if identical implementations are to be obtained. The X12 began writing implementations guides during calendar year 1996 for version 3070. None have yet been tested between operating trading partners. No draft data dictionary is yet available.

E)There currently is only one implementation guide for the Consolidated Service Invoice/Statement (811) - Payment Order/Remittance Advice (820) for the purposes of health plan premium payments.

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance:

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

C)Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards as costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity:

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards:

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

G) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

H)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

I)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

First Report of Injury:

Accredited Standards Committee X12 Insurance Subcommittee, Property And Casualty Task Group

ANSI Accreditation

X12 was accredited as an ANSI accredited standards committee in 1979. Subsequent X12 procedure changes have required ANSI re-accreditation which was last granted in 1987.

The main objective of ASC X12 is to develop Electronic Data Interchange (EDI) standards to facilitate electronic business transactions (i.e. order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions). ASC X12 endeavors to structure standards in a manner that computer programs can translate data to and from internal formats without extensive reprogramming.

This strategy allows companies to maximize their resources required for internally developed or commercial software (recommended) and private or public-access communication networks. ASC X12 believes that all sizes of companies using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties incurred from each organization using its own formats to transact business. Within ASC X12, the various subcommittees are responsible for developing standards in their area of expertise. Once a subcommittee has developed a draft standard the full ASC X12 membership reviews and approves it according to the operating policies and procedures. All standards (new or changed) require the consensus approval of the full ASC X12 membership. The approved standard becomes a draft standard for trial use for a reasonable trial period. After the trial period the draft standards are submitted to ANSI to become an American National Standard (ANS).

Report of Injury, Illness or Incident (148)

Contact For More Information: Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standard:

A) The objective of the Report of Injury, Illness or Incident (148) is to facilitate the first report of an injury, incident or illness.

B)This transaction set can be used to report information pertaining to an injury, illness or incident to entities interested in the information for statistical, legal, and claims and risk management processing requirements.

C)This transaction is used for administrative reporting requirements.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has been developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard:

A) The Report of Injury, Illness or Incident (148) is not a guideline. However the X12 Insurance Subcommittee is currently developing an implementation guide.

B)The Report of Injury, Illness or Incident (148) standard is fully implementable. The transaction set was approved as a Draft Standard for Trial Use (DSTU).

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)This standard does not require an implementation guide. ASC X12 has published four Type II Tutorial reports or tutorials for version 003041 in October of 1994, version 003050 in October 1995, version 003051 in February 1996, and version 003060 in April of 1996. To facilitate consistent implementation across the health care industry, the X12 Insurance Subcommittee is currently in the process of completing five implementation guides for version 003070 encompassing medical, hospital, dental, pharmaceutical claims, and workers compensation jurisdictional reporting with an anticipating publication date of April 1997.

E)There currently is only one implementation guide for the Report of Injury, Illness or Incident (148).

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance:

A) The X12 standards are made available via many sources including the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Every government contractor has been funded by the Health Care Financing Administration (HCFA) to implement the ASC X12 standards. Many other payers have followed HCFA's lead and implemented the standards as well. Many other payers have followed HCFA's lead and implemented the standard as well.

C)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

D)Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards as costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity:

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards:

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

G) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

H)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

I)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

Health Level Seven (HL7)

Emergency room message being developed with Centers for Disease Control (CDC). See detailed information regarding HL7 in the Claims section.

ASTM Committee E31 on Healthcare Informatics

Organized in 1898, ASTM (the American Society for Testing and Materials) has grown into one of the largest voluntary standards development systems in the world. ASTM is a not-for profit organization that provides a forum for producers, users, ultimate consumers, and those having a general interest (representatives of government and academia) to meet on common ground and write standards for materials, products, systems, and services. From the work of 132 standards-writing committees, ASTM publishes more that 9000 standards. ASTM headquarters has no technical research or testing facilities; such work is done voluntarily by 35,000 technically qualified ASTM members located throughout the world. ASTM provides continuing education and training in the use and application of ASTM standards through Technical and Professional Training courses. In 1987, ASTM formed the Institute for Standards and Research (ISR). The purpose of the Institute is to provide a mechanism for conducting research to improve the quality and timeliness of ASTM standards. It does no research, but serves as the intermediary between the standards-writing community and the public or private agencies that could provide appropriate research and technical services, or supply funding for such research.

ANSI Accreditation

ASTM is an ANSI Accredited by the Organization Method. All ASTM Committee E31 standards are approved as American National Standards.

E1744-95, Standard Guide for a View of Emergency Medical Care in the Computerized Patient Record

Contact For More Information

Manager - Committee E31, ASTM

Barr Harbor Drive

West Conshohocken, PA 19373

Ph: 610-832-9500

Fax: 610-832-9666

Description of Standard

This guide covers the identification of the information that is necessary to document emergency medical care in a computerized patient record that is part of a paperless patient record system designed to improve efficiency and cost-effectiveness. It details the use of data elements already established for emergency care in the field or in a treatment facility and places them in the context of the object models for health care that will be the vehicle for communication standards for health care data. The codes for the data elements referred to in the document will be developed in consideration of national or professional guidelines whenever available. The EMS definitions are based on those generated from the national consensus conference sponsored by NHTSA and from ASTM F30.03.03 on EMS management information systems. The Emergency Department (ED) definitions will consider those recommended by the Data Elements for Emergency Department Systems workshop sponsored by CDC, NHTSA, and other public and private organizations. The hospital discharge definitions will be developed in consideration of existing requirements for Medicare and Medicaid payment. The ASTM process allows for the definitions to be updated as the national consensus changes. When national or professional definitions do not exist, or whenever there is a conflict in the definitions, the committee will recommend a process for resolving the conflict or present the various definitions within the document along with an explanation for the purpose of each definition.

This view reinforces the concepts set forth in E-1239 and E-1384 that documentation of care in all settings must be seamless and be conducted under a common set of precepts using a common logical record structure and common terminology. The computerized patient record focuses on the patient and includes information about the occurrence of the emergency, symptoms requiring emergency medical treatment, medical/mental assessment/diagnoses established, treatment rendered, outcome and disposition of the patient after emergency treatment. It consists of subsets of the data computerized by multiple care providers at the time of onset/scene and enroute, in the emergency department, in the hospital or other emergency health care settings. The computerized patient record focuses on the documentation of information that is necessary to support patient care but does not define appropriate care.

Readiness of Standard

This guide is a "view" of the data elements to document the types of emergency medical information that would be valuable if available in the computerized patient record. As a view of the computerized patient record, the information presented will conform to the structure defined in other ASTM standards for the computerized patient record. This guide is intended to amplify Guides E 1239, E 1384, and F 1629 and the formalisms described in Practice E 1715. It is implementable in that it consists of a list of data elements important to emergency medical care that vendors can include in their data systems. The guide does not include attribute values for each of the data elements. However, most of these data elements are already defined in the other documents as indicated in Section VI. (The EMS definitions are based on those generated from the national consensus conference sponsored by NHTSA and from ASTM F30.03.03 on EMS management information systems. The Emergency Department (ED) definitions will consider those recommended by the Data Elements for Emergency Departments Workshop sponsored by CDC, NHTSA, and other public and private organizations. The hospital discharge definitions will be developed in consideration of existing requirements for Medicare and Medicaid payment.) The guide is currently being revised to include the attribute values. The guide may be obtained for a fee from ASTM.

The standard is published and is an American National Standard. How can the standard be obtained? ASTM standards are available through the ASTM Customer Service Department by calling 610-832-9585. Standards can also be ordered through the ASTM Web Site at www.astm.org

Indicators of Market Acceptance

Approximately 2300 copies of the E31 standards have been distributed.

The Guide will be incorporated into the overall standards for the computerized patient record and is not designed to stand alone.

Level of Specificity

Same as information under VII.

Relationships with other Standards

There are no other similar Standards related to emergency medical care that have been developed by an authorized SDO. Defacto standards developed by the organizations listed in VI include data sets that have been developed during a formal consensus process (EMS), through broad participation by all stakeholders (ED) or through the payment of public funds (hospital). The definitions developed during these efforts will be incorporated into the next revision of E-1744.

Health Claim Status

Accredited Standards Committee X12 Insurance Subcommittee, Property and Casualty Task Group

ANSI Accreditation: X12 was accredited as an ANSI accredited standards committee in 1979. Subsequent X12 procedure changes have required ANSI re-accreditation which was last granted in 1987.

The main objective of ASC X12 is to develop Electronic Data Interchange (EDI) standards to facilitate electronic business transactions (i.e. order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions). ASC X12 endeavors to structure standards in a manner that computer programs can translate data to and from internal formats without extensive reprogramming.

This strategy allows companies to maximize their resources required for internally developed or commercial software (recommended) and private or public-access communication networks. ASC X12 believes that all sizes of companies using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties incurred from each organization using its own formats to transact business. Within ASC X12, the various subcommittees are responsible for developing standards in their area of expertise. Once a subcommittee has developed a draft standard the full ASC X12 membership reviews and approves it according to the operating policies and procedures. All standards (new or changed) require the consensus approval of the full ASC X12 membership. The approved standard becomes a draft standard for trial use for a reasonable trial period. After the trial period the draft standards are submitted to ANSI to become an American National Standard (ANS).

Health Care Claim Status Request (276)

Health Care Claim Status Notification (277)

Contact For More Information: Data Interchange Standards Association (DISA) 703-548-7005.

Description of Standards

A) The objective of the Health Care Claim Status Request (276) - Health Care Claim Status Notification (277) is to determine the status of a submitted claim.

B)This transaction set pair can be used to request the status of a submitted claim by the health care provider using the Health Care Claim Status Request (276) and the payer to respond to these inquiries using the Health Care Claim Status Notification (277). The Health Care Claim Status Notification (277) can be used independently of the Health Care Claim Status Request (276) for the purposes of an unsolicited claim status from the payer to the health care provider as well as payer requests for additional information from the health care provider.

C)This transaction is used to support administrative reimbursement for health care products and services.

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has been developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard

A) The Health Care Claim Status Request (276) - Health Care Claim Status Notification (277) is not a guideline. However the X12 Insurance Subcommittee is currently developing an implementation guide.

B)The Health Care Claim Status Request (276) - Health Care Claim Status Notification (277) standard is fully implementable. The transaction set was approved as a Draft Standard for Trial Use (DSTU) in October of 1993 as Version 003040.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)This standard does not require an implementation guide. ASC X12 has published four Type II Tutorial reports or tutorials for version 003041 in October of 1994, version 003050 in October 1995, version 003051 in February 1996, and version 003060 in April of 1996. To facilitate consistent implementation across the health care industry, the X12 Insurance Subcommittee is currently in the process of completing five implementation guides for version 003070 encompassing medical, hospital, dental, pharmaceutical claims, and workers compensation jurisdictional reporting with an anticipating publication date of April 1997.

E)There currently is only one implementation guide for the Health Care Claim Status Request (276) - Health Care Claim Status Notification (277).

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

C)Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards as costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity:

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

A) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

B)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

C)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

D)Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

E)ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

A) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

B)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

C)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

D)The current use of proprietary formats such as the National Standard Format (NSF) and the costs of maintaining these formats far outweigh the costs associated with implementing a single set of the health care industry standards from ASC X12.

ASC X12 Claim Status (276/277) was approved October 1993. This transaction is used to determine the status of a submitted claim. The Implementation Guide is in development and is expected to be approved June 1997.

Referral Certification and Authorization

Accredited Standards Committee X12 Insurance Subcommittee, Property and Casualty Task Group

ANSI Accreditation: X12 was accredited as an ANSI accredited standards committee in 1979. Subsequent X12 procedure changes have required ANSI re-accreditation which was last granted in 1987.

The main objective of ASC X12 is to develop Electronic Data Interchange (EDI) standards to facilitate electronic business transactions (i.e. order placement and processing, shipping and receiving, invoicing, payment, cash application data, insurance transactions). ASC X12 endeavors to structure standards in a manner that computer programs can translate data to and from internal formats without extensive reprogramming.

This strategy allows companies to maximize their resources required for internally developed or commercial software (recommended) and private or public-access communication networks. ASC X12 believes that all sizes of companies using intelligent computational devices can benefit from the use of the standard. The efficiencies of standard interchange format can minimize the difficulties incurred from each organization using its own formats to transact business. Within ASC X12, the various subcommittees are responsible for developing standards in their area of expertise. Once a subcommittee has developed a draft standard the full ASC X12 membership reviews and approves it according to the operating policies and procedures. All standards (new or changed) require the consensus approval of the full ASC X12 membership. The approved standard becomes a draft standard for trial use for a reasonable trial period. After the trial period the draft standards are submitted to ANSI to become an American National Standard (ANS).

Health Care Service Review Information (278)

Contact For More Information: Data Interchange Standards Association (DISA) 703-548-7005.

Description Of Standard:

A) The objective of the Health Care Service Review Information (278) is used for referral certification and authorization.

B)This transaction set can be used to request and transmit demographic, utilization, certification and referral information. Includes no Utilization Management treatment information.

C)This transaction is used to support administration of health care services review between payers, providers, plan sponsors, and utilization review organizations..

D)This standard may be used from any operating system, network, or hardware platform.

E)The standard has be developed with widespread input from the health care industry incorporating all business needs into its functionality.

F)The ANSI ASC X12 is the only nationally recognized EDI standards development organization in the United States for all type of electronic commerce. ASC X12 is the organization assigned by ANSI to represent the United States in the development of International EDI standards.

G)Standards. These standards are developed using a consensus process by the users in the health care industry.

H)The standards developed by ASC X12 may be translated to/from application systems using off the shelf translation software products which are used by all industries utilizing the ASC X12 standards.

Readiness of Standard:

A) The Health Care Service Review Information (278) is not a guideline. However the X12 Insurance Subcommittee is currently developing implementation guides for this transaction.

B)The Health Care Service Review Information (278) standard is fully implementable. The transaction set was approved as a Draft Standard for Trial Use (DSTU) in October of 1994 as Version 003050.

C)The standard can be obtained by contacting the Data Interchange Standards Association (DISA) at 703-548-7005.

D)This standard does not require an implementation guide. ASC X12 has published four Type II Tutorial reports or tutorials for version 003041 in October of 1994, version 003050 in October 1995, version 003051 in February 1996, and version 003060 in April of 1996. To facilitate consistent implementation across the health care industry, the X12 Insurance Subcommittee is currently in the process of completing five implementation guides for version 003070 encompassing medical, hospital, dental, pharmaceutical claims, and workers compensation jurisdictional reporting with an anticipating publication date of April 1997.

E)There currently is only one implementation guide for the Health Care Service Review Information (278).

F)The implementation guides will specify the conformance to the standards.

G)Yes, conformance tools are commercially available.

H)The same tools used for conformance may also be used as testing tools.

I)The standard is complete. The current version of the standard is 003070. As business needs dictate, enhancements may be made to the standard three times per year, one major release along with two subsequent sub-releases. The X12 Health Care Task Group has developed procedures to determine when to move to the next version of the standard as well as when to retire past versions. The Health Care Task Group will also determine the need for new versions of the implementation guides (not more frequently than once per year).

J)Currently no enhancements are under development.

AA) This standard has been completed.

BB) This standard has been completed and undergoing industry implementation.

Indicator of Market Acceptance:

A) The X12 standards are made available via many sources including from the Data Interchange Standards Association, Washington Publishing (ASC X12 Insurance Subcommittee's publisher), industry user groups and associations, and the Internet. Due to the multiplicity and diversity of these distribution methods, it is not possible to determine how many copies have been distributed and to whom.

B)Yes. ASC X12 represents international standards development. North American and other countries have implemented ASC X12 standards for purchasing and financial transactions. It would be to their benefit to further leverage their investment in EDI translation software, hardware and communication infrastructure to utilize the health care transactions.

C)Over 300 payer, provider, vendor, and plan sponsor organizations currently participate in the development of the ASC X12 standards and implementation guides to meet the business needs of the entire health care industry. These organizations have experienced the benefits of mature standards as costs associated with developing and maintaining proprietary formats far exceed the investment necessary to implement a single set of health care EDI transactions.

Level of Specificity:

A) The ASC X12 EDI transactions have been developed to meet the specific business needs identified by the standards developers and the health care industry.

B)See attached table of contents from the ASC X12 Insurance Committee's implementation guides.

C)ASC X12 standards incorporate the business requirements for exchanging information contained within other standards. The ASC X12 standards provides a vehicle for communicating other standards within the standards.

D)ASC X12 maintains over one thousand internal code sets to support the standards. Along with the internal code sets the ASC X12 standards reference over 350 external code sources such as:

• Current Procedural Terminology (CPT) Codes from American Medical Association
• Current Dental Terminology (CDT) Codes from American Dental Association
• International Classification of Diseases Clinical Modification - (ICD-9-CM) Diagnosis from U.S. National Center for Health Statistics.

H) There are too many code sets to describe here. Refer to the ASC X12 standards publication.

I)Internal code sets are included within the ASC X12 standards publications and implementation guides. When external code sets are referenced within these documents, the source where the code sets can be obtained is listed.

J)When possible, the implementation guides will either include the external code sets or provide further information on how to obtain the external code sets. Internal code sets are included within the implementation guides.

AA) Internal code sets are available to all users of the ASC X12 standards. Usage of the external code sets will vary by source and their ability to promote the usage of their code sets.

BB) ASC X12 internal code sets follow the same processes defined for the development and maintenance of the EDI transactions. External code lists are maintained by the external code source's internal development procedures.

Relationships With Other Standards:

A) ASC X12 strives to coordinate and incorporate the needs of the other standards development organizations such as Health Level 7 (HL7), National Council for Prescription Drug Programs (NCPDP), and the American Society for Testing and Materials into the ASC X12 standards.

B)See A).

C)See A).

D)Open communication in the development of the standards amongst the standards development organizations.

E)ASC X12 is the ANSI appointed standards development organization responsible for international EDI standards within the United States

F)None

G)Given the scope and responsibility for the development and maintenance of the EDI standards for the United States and the international community with respect to United States international standards, ASC X12 is only privy to the business needs which are brought forward and coordinated with other health care organizations. At this time, we are unaware of any gaps in the current standards for insurance.

Identifiable Costs:

A) None applicable. ASC X12 does not license it standards.

B)The cost of acquiring the ASC X12 standards publication varies depending upon the source of the publications. Currently they are available from:

• Data Interchange Standards Association (DISA) 703-548-7005.
• Washington Publishing Corporation 800-972-4334
• Industry user groups and associations
• The Internet (http://www.disa.org, http://www.wpc-edi.com)

A) The typical cost ranges from free to $415.00 for the full ASC X12 standards publication in either paper form or CD-ROM.

B)The cost/timeframe for education and training will depend upon the individuals and skill levels of the individuals within an organization. Some organizations have completed education and training within one week while others have taken longer.

C)The cost/timeframe for implementation depends upon the internal systems capabilities, systems development philosophy, hardware platform selected, EDI translator software, communication methodology and individual resources within an organization. Costs can range anywhere from free for a personal computer solution to well over $150,000 for midsize and mainframe systems. Some organizations have implemented the standards within a matter of days while other have taken months to achieve the same end result.

D)The current use of proprietary formats such as the National Standard Format (NSF) and the costs of maintaining these formats far outweigh the costs associated with implementing a single set of the health care industry standards from ASC X12.

ASC X12 Healthcare Service Review (278) was approved February 1996. This transaction is used to request and transmit demographic, utilization, certification and referral information. The Implementation Guide is in development and is expected to be approved June 1997.