Avoiding a Wipeout!

Spring ConferenceApril 4, 2008

EDI Session 1

Gary BeattyPresidentEC Integrity, IncVice-Chair ASC X12

HIPAA Adopted Versions◦ 004010 - May 2000◦ 004010 Addenda – October 2002

HIPAA Deadlines◦ October 16, 2002 – Original Implementation◦ October 16, 2003 – ASCA Extended

Implementation◦ Contingency Plans

DSMO◦ Processed over 1000 change requests◦ ~500 changes since 004010

X12◦ Has processed additional industry change

requests since 004010◦ IG’s are now Technical Report Type 3 – TR3

005010 – First X12 TR3 9 - TR3’s for the current HIPAA adopted transactions 10 – Additional TR3’s for possible HIPAA adoption

Acknowledgements Health Care Claim Attachments

X12◦ Continuous TR3 development cycle◦ Learning from past experiences◦ More industry coordination – DSMO

National Uniform Billing Committee (NUBC) National Uniform Claim Committee (NUCC) Dental Content Committee (DeCC) Health Level 7 (HL7) National Council for Prescription Drug Programs

(NCPDP) X12 Public Comment Period NPRM Comment Period

Business value for change◦ Increasing inability of 004010 to support industry

business needs.◦ Ability to synchronize current HIPAA transactions

with health care claim attachment transactions ◦ Added flexibility

Moved some codes to external code lists

ICD-10 Support◦ Added capability to communicate

ICD-10-CM Diagnosis ICD-10-PCS Procedure Codes

◦ Improves the capture of information about the increasingly complex delivery of health care.

◦ Greater coding accuracy and flexibility opportunities for detailed record-keeping and

enhanced documentation to support accurate payment.

Aesthetics◦ Table of Contents

Reformatted for consistency across all TR3’s Content

◦ Consistency between TR3’s◦ Greater flattening of Segments (single

functionality)◦ Added new business functions◦ Modified existing business function for efficiency◦ Front Matter improvements◦ Alignment with HIPAA Privacy Rules◦ Uniform content for Subscribers, Members, and

Dependents

◦ Removed ambiguity Removed “Should”, “Could”, “May” Replace with:

Form A —“Required when <explicit condition statement>. If not required by this implementation guide, may be provided at the sender’s discretion but cannot be required by the receiver.”

Form B —“Required when <explicit condition statement>. If not required by this implementation guide, do not send.”

Situations: More definitive Closed loopholes to prevent

Payer-specific requirements due to the TR3 not restricting data

Providers from sending data beyond the minimum necessary needed for the business function –which would require explanatory documentation

◦ Clarified mechanism to communicate National Provider Identifier (NPI)

◦ Allows code set changes to occur rapidly using X12’s Code Maintenance Request and HIPAA non-medical code set adoption processes –as dictated by real-time evolving business needs

270/271◦ Added enhanced and highly specific search

requirements for matching individuals covered by health plans: subscribers, members, dependents

◦ Added much more detailed eligibility, coverage, or benefit responses Plan and benefit begin dates Plan name Primary care physician (if applicable) Other health plans (if known) 10 high level benefits All demographic information needed to identify the

individual in all other subsequent EDI transactions

837◦ Modified subscriber and patient hierarchy◦ Added National Provider Identifier (NPI) reporting

rules◦ Clarified use of Pay-To Provider◦ Made provider type definitions consistent◦ Clarified Coordination of Benefit reporting rules◦ Clarified drug claim reporting rules◦ Clarified Medicaid subrogation processing rules

835◦ Removed “Not Advised“ code value usage

language◦ Refined reversal and correction instructions;

particularly for Prompt pay discounts Interest

◦ Added new segments to communicate Health Care Policy Remittance Delivery Method

◦ Enhanced claim status definitions

276/277◦ Improved consistency of subscriber and

dependent identification data◦ Improved capabilities for processing prescription

claims Added use of prescription numbers Added use of NCPDP reject / payment codes

◦ Enhanced capabilities to communicate patient, provider, and payer control / tracking numbers

◦ Expanded capabilities to send more complete and detailed status information

278◦ Restructured to support patient and service event

level requests◦ Enabled service level to support Institutional,

Professional and Dental detailed segments◦ Clarified patient condition segments◦ Added medical service reservation: Medicaid◦ Allowed for multiple reject reason codes◦ Added support for

Reconsideration requests Subscriber and dependent mailing addresses Transport Other UMO

834◦ Clarified the differences and uses of

Change Update Full File Replacement Full File Audit

◦ Added new control totals for Employee Total Dependent Total Transaction Total

◦ Added codes to specify reason for Medicare eligibility

834◦ Added capabilities to communicate

Class of Contract Service Contract Number Medical Assistance Category Program Identification Numbers

◦ Added ability to indicate patient confidentiality and alternate information delivery addresses

◦ Added capabilities to report individual financial amounts related to the member’s responsibility; including Medicaid Spend Down amounts

820◦ Added ability to apply adjustments to

Entire transaction –not just individual members Past payments

◦ Added the capability to communicate additional deductions Service Promotion Allowance Charge

Detailed TR3 Changes Documentation◦ Summary in Appendix D of each 005010 TR3◦ Body of each 005010 TR3

Function Standard TR3Enrollment 834 005010X220Premium Payment 820 005010X218Eligibility 270/271 005010X279Services Review 278 005010X217Professional Claim 837P 005010X222Institutional Claim 837I 005010X223Dental Claim 837D 005010X224Claim Status 276/277 005010X212Claim Payment 835 005010X221

All TR3’s are approved for publication◦ Available at:

◦ Copyright changes

www.x12.org

Federal rule making process to adopt 005010◦ Draft Proposed Regulation◦ Internal Clearance

CMS DHHS OMB

◦ Publish NPRM for public comment (? Days)◦ Draft Final Regulation◦ Respond to comments (in Final Regulation)◦ Internal Clearance

CMS DHHS OMB

◦ Publish Final Regulation (publication date) 30/60 day Congressional Review (effective date) 2 Years for industry to implement (compliance date)

Claim Attachments◦ 277 Request for Additional Information◦ 275 Patient Information

HL7 Clinical Document Architecture Acknowledgements

◦ 999 Implementation Acknowledgment◦ TA1/TA3 Interchange Acknowledgments◦ 824 Application Advice◦ 277 Health Care Claim Acknowledgment

269 Health Care Benefit Coordination Verification Request and Response 

Be Proactive not Reactive◦ Do not wait for the NPRM to review 005010 TR3’s◦ If you need more time ask for an extension

Gary BeattyPresidentEC Integrity, IncVice-Chair ASC X12

Questions

Thank you !

WEDI X12 Pre-conference Forum: HIPAA X12 005010 Transaction Enhancements

Held in conjunction with the 17th Annual WEDI National Conference

Monday, May 19, 2008Hyatt Regency Baltimore on the Inner Harbor