Inventory of Health Care Information Standards. ASC X12N Interactive Healthcare Claim/Encounter (IHCLME)

01/01/1997

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.