Skip to main content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.


The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

July 9, 1997 Public Forum: Enrollment and Eligibility

DR. MOORE: Thank you. We have the enrollment and eligibility implementation team to go over the other five transactions that we didn't cover before lunch. After we do this presentation we will take a short break again of ten minutes, and then proceed with the medical code sets and the security.

MR. MOORE: Thank you. The person to do this is David Clark with HCFA, who is the chair -- or right now, to be co-chair of that particular team.

DR. CLARK: Thank you, Bob. Good afternoon, everyone. What I would like to go over is just to share with you the charge of the team, talk a little bit about some of the recommendations or the thinking as it presently exists within the group. I would also like to walk through each of the transactions, share with you a little bit about the status and some of the issues that we are looking at.

Before I begin, I would like to just talk about the team a little bit. As Bob said, it is a group effort, and we have really struggled to make sure that the spin is understood within the community, that it is not a HCFA effort in terms of developing these standards, that there really is a very broad effort within the federal government to bring about and develop these standards.

On the eligibility and enrollment team, I have Deborah Bills with HCFA, who has been assisting me and acting as a co-chair up until the last couple of weeks. The Department of Defense identified Steven McMilly as a co-chair to be assisting with the rest of this project.

In addition to Steven, Duane Goodenow is on the team from the Department of Defense. We also have representation from the Office of Personnel Management, the Veterans Administration, and then a somewhat unique arrangement with the Department of Labor and OSHA, Bureau of Labor Statistics, as well as its Office of Workman's Compensation programs.

I understand that Jean was in the audience and so was Judy, and I believe Duane is here as well. I would like for them to just stand up, please, if they are available. They seem to have gotten away from us.

Let me start with the charge of the group. Basically, we are responsible for five of the 11 transactions that were named in the legislation. That would include the enrollment transaction for checking and testing the enrollment of various individuals in a health plan, the eligibility requirements in terms of the services that they are eligible to receive. We are also responsible for the first report of injury, which is really not a health standard, and we'll talk about that a little bit. It is outside of the scope of the health delivery system. We are also responsible for health premium payments. Then the last one, referral certification and authorization for specialty services that are received within a plan.

In terms of the recommendations, where we are at this point, for the enrollment transaction, we are looking at the ANSE X12.834, the version 3070. For the first report of injury, it is the X12.148. For premium and billing payment, we are looking at the ANSE X12. It says 811 and 820, although at this point our efforts are really focusing on the payment side of the transaction, which would be the 820.

For health care services review, we are looking at the ANSE X12.278. Then the last one for eligibility, the ANSE X12.270-271.

Under enrollment, the current implementation guide covers all forms of benefits. It is narrower in scope for the health care specific guide. In terms of policies, what we are looking at is whether or not -- how we will incorporate the whole issue of race and ethnicity into the standard. There are some providers and plans that would like to see a fairly broad bucket, if you will, an ability to identify the race and ethnicity of the different members within the plans.

There is a great deal of variation across the country in terms of out West, looking at a little bit more specific information requirements. At this point, we are very anxious to see the OMB directive 15 in the Federal Register. I believe that is soon to be published, which will give us some guidance in terms of how to approach this particular issue.

Also, there is the whole question of performance measures and outcomes research, and how is that to be addressed, or even if it is covered by HIPAA, in regards to the HETUS data or even data from the Foundation for Accountability.

With the 834, basically we have a good draft of an implementation guide that is ready. We have identified the changes on the federal side. We expect to have a data dictionary ready, as well as drafting some of the industry requirements.

Our target date is August 25 to have the data dictionary completed. Looking at the interim meeting for ANSE in mid-August, we may be able to have additional and more specific information about the transaction and how it will appear in the regulation.

The first report of injury is rather unique, and really outside of the purview of the health system. It is more of the insurance industry, in terms of reporting workman's compensation claims, something that HCFA has relatively little or no experience with. We have been working with the Department of Labor through its Office of Workman's Compensation programs. That is Bureau of Labor Statistics, which is also interested in some of the data that comes out of this transaction, as well as OSHA.

There is no current implementation guide available. There was a draft guide that is being worked on in a tutorial. I believe it is a version 3040 that we are working with the chairs of the ANSE work group on, in terms of looking at how this transaction can be used within the HIPAA requirements, and whether or not it would meet the requirements for the Department of Labor, as well as states in terms of reporting workman's compensation issues.

As I indicated, it is not a health specific transaction. It is outside of HHS purview. I mentioned the groups that are working on this with us.

Some of the policy issues, how can we expand this or should we expand it to include allowing physicians to make a first report, as opposed to coming from the employers or through the state. Again, given our lack of experience with this particular transaction, we may need to engage the private sector workman's compensation community to assist us a little bit in looking at this particular transaction.

There is another area that we are looking at with the 148, which involves the Food and Drug Administration. Evidently they have a reporting requirement for devices which they are in the process of developing standards for as well. I am in communication with Mr. Haffman over at the FDA, to see whether or not these particular transactions and the standards and the data elements that we are looking at under the 148 can and will include what he is trying to do for the devices, in terms of reporting injury through the different devices.

We are looking at that. Our expectation just from a preliminary conversation was that that material really is much broader in scope than what we are looking at in 148 for the first report of injury, and will in all likelihood continue down two separate and different paths.

In terms of premium billing and payment, it is used in the industry as an ANSE finance function, much broader than the health care opportunities for use within the health industry for premium payments, either through our side in HCFA, through the federal government for making payments to the states or different providers.

There is no implementation guide available for that, so it is something that we are going to have to build ourselves. Our expectation is that the HIPAA transactions or the HIPAA use would not be very complicated. It would be much smaller in scope than what is currently in the 820 or the 811 on the billing side.

In terms of health care services review, there are multiple implementation guides that are available. I mentioned most of limited of any actual use for us. I mentioned the use of the 278 in terms of the standard that we would be looking at, making a recommendation through the Secretary. We understand that there is a pilot project underway within Blue Cross/Blue Shield, taking a look at the 278. We are very interested in the results of that activity.

It is one that we are not really focusing a lot of energy on at this point. There may be a late deliverable for this one after the February '98 date, sometime mid or late spring.

In terms of eligibility with the ANSE 270-271, right now we are near completing the mapping of the government data element requirements for this particular transaction. All the necessary components are in place to produce the regulation. We have identified some 161 data elements in the 270, approximately 327 elements in the 271. Most of these are optional elements, fortunately. We continue to develop and make the final process for the data dictionary for the various data elements.

We have made a decision that we are not doing interactive eligibility transactions within the 270-271.

In terms of the data dictionary, it will include the listing of names, definitions, transactions and locations. It will be organized by individual transaction. It will not include the codes for the values nor the implementation instructions. We are looking toward the implementation guides to carry that information.

I just want to wrap up by saying a little bit about the regulation itself, because that ultimately is the end game for us in terms of each of these transactions that we have been working on. We are looking at basically pulling information together into one regulation with a preamble, which will cover the background information, in terms of how the particular standard was identified and selected. We will also explain that the standard data organizations will continue their processes for maintaining the standard. We hope to explain how the modifications process would be carried out, the change control forms.

We will also include in the preamble some information -- or hope to include information concerning the evaluation guide, the criteria that we used to select the different standards. There of course will be the impact analysis that we have, which we are pulling together the data right now in terms of the cost of implementing these various standards.

There is a huge debate internally, just in terms of whether or not we will be looking at electronic comments on the regulation as it comes out in terms of an electronic rulemaking process.

There will be addenda for each of the transactions which will include a cross reference for each transaction to the following: the ANSE requirements, the standard itself, as well as the implementation guide. We will also have in the addenda for each transaction the data dictionary, which we hope to identify and label a definition and whether or not that particular element is required or optional.

That concludes the materials that we are looking at for the enrollment team, in terms of the five transactions that we are looking at. We hope to be in place with most of the information that you will need to give us feedback on what we have done by the ANSE meeting in August.

Thank you. Are there any questions or feedback for us?

DR. OWENS: Just a comment on all three implementation guides that you mentioned, the premium billing and payment and the first report of injury and illness. Those are all being worked on and are anticipated being done at the August meeting of X12.

DR. CLARK: Yes. The question was whether or not the implementation guides that we are working on internally within the work group, the 148, the premium payment, which is the 820, and the 834 are all being worked on internally. The answer is yes, and they will be available at the ANSE meeting in August.

DR. ROBINSON: On your last slide on the 834, on the enrollment, you talked about one of the outstanding issues being performance measurement and outcome results, or something along those lines. What are you envisioning including there? I didn't quite catch what was meant by that line in the slide.

DR. CLARK: The question was raised concerning one of the slides on the 834, where we were raising the issue of what are the HIPAA requirements with respect to some of the outcomes research activities. There, what we are looking at is like with HETUS data. Now that the plans are required to submit HETUS data to HCFA, is that something that ought to be included under the HIPAA requirements, and are there standards or data elements that we would need to include under HIPAA for collecting that information.

That was just one, and it is more an internal debate within the work group, in terms of how broad the scope of HIPAA would cover.

DR. ROBINSON: I just don't see that transaction being the place for that kind of information, since it is coming from the employer in the first place. So they wouldn't know that information relative to the health plan.

My second question is, just because I don't know what it is, what is the OMB Directive 15?

DR. CLARK: The question is regarding the OMB Directive 15. What that is, is a federal regulation that requires for an internal reporting of race and ethnicity, based on specifically defined categories for race and ethnicity. A lot of controversy around it in terms of even whether or not the federal government should be collecting race and ethnicity data, how do we want to include that into the standards, whether or not it will be used. It is along that line.

DR. ZUBELDIA: I have two questions about eligibility. Have you looked at having minimum and maximum data requirements for eligibility, so a payer cannot be asking for basically everything on an eligibility inquiry? Then answering with a yes-no answer, but actually giving some extensive data in the answer. Have you looked at that, like we discussed about maximum data requirements for a claim?

DR. CLARK: No, we haven't, not within the group. I can certainly take that back within the team. I think the -- is that in regards to the huge number of elements in the 271, where we are looking at some 271 elements with roughly about 50 of them being required elements?

DR. ZUBELDIA: Well, it has both sides. The 271 response can say the patient is covered or is not covered, and stop there. Or it can give additional coverage information. On the other hand, on the inquiry, you can be asking for a lot of information, basically all of the eligibility information, and then you will turn around and say, yes, it is covered or it is not covered. You can use it in many different ways. I think that beyond saying this is the transaction itself, you need to standardize how it is doing to be used.

The other question that I have on -- I forgot about it. I'll come back.

PARTICIPANT: I also have a question regarding eligibility. I come from Massachusetts, where both the Bushiell plan and the state Medicaid uses magnetic card read swipe boxes, which are both proprietary to each organization. Under the law, if you are picking the 834 transaction, would those boxes have to be changed to accept the ANSE transaction, and if so, why are you using the 270 non-interactive as opposed to the ICEBER, which would be a reduced set?

DR. CLARK: I don't have the answer for that right now. I would like to capture the question specifically, and can respond to you at a later time. John, was there any comments that you would make on that?

DR. ST. GEORGE: Well, if we follow the same statements that have been made about the federal law, then yes, they would have to change those to use the transactions as specified by the federal law, just as we talked about with the claims.

In terms of the interactive, our group wasn't involved in the team's decision with that, but not everybody supports interactive transactions. But the 270-271 support, what is called fast batch, which means you can make an inquiry and get an immediate response, is just not a true interactive response. It is a single batch in, single batch back. Kepa knows all about interactive.

DR. ZUBELDIA: Well, no, but this has refreshed my memory, and it also goes with the interactive issue. I thought you mentioned that the interactive eligibility was being left out of HIPAA. So if they are doing an interactive eligibility, they don't have to do the 270 and 271.

My question that I forgot before was, if they are using batch eligibility, even if it is fast batch with 270-271, is there a required maximum response time? Or can I send an eligibility inquiry today and the payer will answer back a week later, or three days later, like is the case today with some payers?

DR. CLARK: The question is, will the standard include a required maximum response time to an inquiry on the 270 transaction. At this point, we haven't made a decision on that. Is there a recommendation in terms of what that time frame might be?

DR. ZUBELDIA: My recommendation would be about 10 to 15 seconds.

DR. CLARK: Okay.

PARTICIPANT: I'm chair of the ANSE Z15.2 committee. We have been working with the insurance industry, the Office of Workers Compensation programs and the Department of Labor's BLS, almost the same groups, all the state workman's compensation commissioners. But our focus was on the coding mechanism and simplifying and standardizing the coding, so that we could better prevent and deal with workplace injuries and illnesses.

I just want to make sure I am invited to your August meeting, so I can try to coordinate the efforts on the ANSE Z16.2 and Z16 committees, and all the X12's, and try to petition ANSE to help you do this in a way that will benefit the working professionals, and try to do it in a way in which we can prevent workplace injuries throughout this country.

So I'll see you after the meeting, and I hope I can get invited to your August meeting.

DR. CLARK: Yes, thank you. Any other questions or comments? Thank you.

DR. MOORE: It is 10 of three. If anyone wants to do jumping jacks to get warm -- by the way, take 15 minutes. That will give us until five after three, and the medical coding and classification team will lead off with that session.