Health Insurance Reform: Standards for Electronic Transactions. b. Effects of Various Options

10/16/2000

We assessed the various options for a standard claim transaction against the principles, listed at the beginning of this impact analysis above, with the overall goal of achieving the maximum benefit for the least cost. We found that the ASC X12N 837 for institutional claims, professional claims, dental claims, and coordination of benefits met all of the 10 guiding principles that were used to designate a standard as a HIPAA standard, but no other candidate standard transaction met all the principles.

Since the majority of dental claims are submitted on paper and those submitted electronically are being transmitted using a variety of proprietary formats, the only viable choice for the standard is the ASC X12N 837. The American Dental Association (ADA) also recommended the ASC X12N 837 for the dental claim standard.

The ASC X12N 837 was selected as the standard for the professional (physician/supplier) claim because it met the principles above. The only other candidate standard, the National Standard Format, was developed primarily by HCFA for Medicare claims. While it is widely used, it is not always used in a standard manner. Thus, we declined to adopt the National Standard Format. Many variations of the National Standard Format are in use. Moreover, the NUCC, the AMA, and WEDI recommended the ASC X12N 837 for the professional claim standard.

The ASC X12N 837 was selected as the standard for the institutional (hospital, nursing facilities and similar inpatient institutions) claim because it met the principles above. The only other candidate standard was the UB-92 Format developed by HCFA for Medicare claims. While the UB-92 is widely used, it is not always used in a standard manner. Consequently, we did not elect to adopt the UB-92.

The selection of the ASC X12N 837 does not impose a greater burden on the industry than the nonselected options because the nonselected formats are not used in a standard manner by the industry and they do not incorporate the flexibility necessary to adapt easily to change. The ASC X12N 837 presents significant advantages in terms of universality and flexibility.