NRPM: Standards for Electronic Transactions. Data Content


[Please label any written comments or e-mailed comments about this section with the subject: Data Content]

We propose standard data content for each adopted standard. There are two aspects of data content standardization: (1) standardization of data elements, including their formats and definition, and (2) standardization of the code sets or values that can appear in selected data elements. A telephone number is an example of a data element that has a standard definition and format, but does not have an enumerated set of valid codes or values. A patient’s diagnosis is an example of a data element that has a standard definition, a standard format, and a set of valid codes. Information that would facilitate data content standardization, while also facilitating identical implementations, would consist of implementation guides, data conditions, and data dictionaries, as noted in the addenda to this proposed rule, and the standard code sets for medical data that are part of this rule. Data conditions are rules that define the situations when a particular data element or record/segment can be used. For example, “the name of the tribe” applies only to Indian Health Service claims. The defining rule for that data element would be “must be entered if claim is Indian Health Service”.

1. Data Element and Record/Segment Content

Once we publish the final rule in the Federal Register and it is effective, there will be no additional data element or record/segment content modifications in any of the transactions for at least one year.

In our evaluation and recommendation for each proposed standard transaction, we have tried to meet as many business needs as possible while retaining our commitment to the guiding principles. We encourage comments on how the standards may be improved.

It is important to note that all data elements would be governed by the principle of a maximum defined data set. No one would be able to exceed the data sets defined in the final rule, until that rule is amended one or more years from the effective date of the final rule. This means that if a transaction has all of the data possible--based on the appropriate implementation guide, data content and data conditions specifications, and data dictionary--then a health plan would have to accept the transaction and process it. This does not mean, however, that the health plan would have to store or use information that it does not need in order to process a claim or encounter, except for audit trail purposes or for coordination of benefits if applicable. It does mean that the health plan would not be able to require additional information, and it does mean that the health plan would not be able to reject a transaction because it contains information the health plan does not want. This principle applies to the data elements of all transactions proposed for adoption in this proposed rule.