NRPM: Standards for Electronic Transactions. Standard: First Report of Injury

05/07/1998

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

Background

“First report of injury” is not a general term or transaction in the health care insurance industry. Upon investigation, we found that the property and casualty insurance industry, among whose lines of business is workers compensation insurance, had developed a standard transaction entitled “Report of Injury, Illness or Incident” (ASC X12N 148). This transaction set was developed within ASC X12N to encompass more than 30 functions and exchanges that occur among the numerous parties to a workers compensation claim. The transaction can be used by an employer, first, to report an employee injury or illness to the State government agency that administers workers compensation and, second, to report to the employer’s workers compensation insurance carrier so that a claim can be established to cover the employee’s losses (income, health care, disability). When the employer is the Federal government, the transaction is used to report to the Department of Labor’s Office of Workers Compensation Programs. In a few States, the transaction can also be used by health care providers to report an employee’s work-related injury to employers and/or the employer’s workers compensation insurance carrier. The transaction can be used by State agencies responsible for monitoring the disposition of a workers compensation claim. Other uses include summary reporting of employee injuries and illness to State workers compensation boards, commissions, or agencies; the Federal Bureau of Labor Statistics; the Federal Occupational Safety and Health Administration; and the Federal Environmental Protection Agency.

The current, approved version of this transaction is 3070, which is not millennium compliant. There is no approved implementation guide for version 4010, which would be millennium compliant. The ASC X12N workgroup is developing a version 4010 or higher implementation guide and data dictionary. The workgroup hopes to secure ASC X12N approval for its revised standard and implementation guide in the spring of 1998. Current workgroup planning is for a single implementation guide that covers all of the business uses to which we refer above.

Recommendation:

We do not recommend that the ASC X12N 148 - Report of Injury, Illness or Incident be adopted at this time, for the following reasons:

a. There is no millennium-compliant version of an implementation guide for this transaction.

b. There is no complete data dictionary for this transaction.

c. The implementation guide under development covers more business requirements and functions than the “first report of injury” specified in the statute.

d. Consultation with the transaction’s extensive user community is necessary to establish a consensus regarding the scope of the transaction set, and this is not possible in the time available to the Secretary for promulgating a final regulation.

e. An alternative to the ASC X12N 148 has been brought to our attention and must be evaluated.

The alternative EDI format is that developed and maintained by the International Association of Industrial Accident Boards and Commissions (IAIABC). The IAIABC EDI format was not identified in the ANSI HISB inventory of standards developed for HHS because the IAIABC is not an ANSI-accredited standards setting organization. Under the law, a standard adopted under the administrative simplification provisions of HIPAA is required to be “a standard that has been developed, adopted, or modified by a standard setting organization” (section 1172(c) of the Act)(if a standard exists). The Secretary may adopt a different standard if it would substantially reduce administrative costs to health care providers and health plans when compared to the alternatives (section 1172(c)(2)(A)).

Accordingly, the IAIABC EDI format must be evaluated before a national standard for first report of injury transactions is adopted because it is reported to be widely used. The IAIABC will be requested to submit documentation so that its first report of injury format can be evaluated according to the ten criteria applied to all other standards.

In assessing the utility of this alternative standard, we will follow the Guiding Principles for selecting a standard to evaluate the IAIABC EDI format against that developed and maintained by ANSI ASC X12N. The following questions about the IAIABC standard will be of particular importance:

a. To what extent is this format widely accepted and used by organizations performing these transactions?

b. Is this format millennium-compliant?

c. Does this standard meet the requirements set forth in the Administrative Simplification provisions of HIPAA for improving the efficiency and effectiveness of the health care system?

d. Is this a format developed, maintained, or modified by a standard setting organization as specified in Section 1171 (8) or does it meet the exceptions specified in Section 1172 (c)(2) of the Act?

We do not recommend that the IAIABC format be adopted at this time. We have asked that the IAIABC provide documentation for their format.

In view of these facts, HHS will take the following actions with regard to adopting a standard for “first report of injury”:

a. Continue to monitor the progress of the ASC X12N subcommittee toward development of a final, complete, millennium- compliant standard, implementation guide, and data dictionary for this transaction.

b. Request that ASC X12N review the ASC X12N 148 to determine whether all of its broad functionality should be included in a standard to be adopted under HIPAA authority or whether the scope of the transaction should be limited by dividing the functions into separate implementation guides.

c. Review and evaluate documentation from the IAIABC on its format so that it can be evaluated according to the ten criteria used to evaluate candidate standards and in relation to the ASC X12N 148 as described above.

d. After the ASC X12N subcommittee has completed its standard setting role and approved a 4010 version or higher implementation guide and data definitions for the ASC X12N 148 and after analysis of the IAIABC alternative standard, issue a subsequent proposed rule promulgating a standard for “first report of injury”.