NRPM: Standards for Electronic Transactions. Transaction Standards

05/07/1998

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

The HISB prepared an inventory of candidate standards to be considered by HHS in the standards adoption process. HHS wrote letters to the NUBC, the NUCC, the ADA, and WEDI in order to consult with them as required by the Act. HHS also consulted with them informally and received their support on all the transactions at various meetings and at the public meeting we held on July 9, 1997, in Bethesda, Maryland. The NCVHS held public hearings during which any person could present his or her views. There also were opportunities for those who could not attend the public hearings to provide written advice, and many did take advantage of that opportunity. In addition, HHS welcomed informal advice from any industry member, and that advice was taken into consideration during the decision making process.

Recommendations for enrollment and disenrollment in a health plan, eligibility for a health plan, health care payment and remittance advice, health plan premium payments, first report of injury, health claim status, and referral certification and authorization were overwhelmingly in favor of ASC X12N implementations. Also, the recommendation for the National Council of Prescription Drug Programs (NCPDP) version 3.2 telecommunication standard format was not controversial and was nearly unopposed.

The recommendations for the professional and institutional claims were quite controversial, with some factions supporting the de facto flat file standards that have been in use for many years and others supporting X12N standards. (A flat file is a file that has fixed-length records and fixed- length fields.) Some associations proposed dual standards with the flat file claim standards (National Standard Format for professional claims and electronic UB-92 for institutional claims) to sunset on a specified date, at which time the parallel ASC X12N claim implementations would become the sole standards to be used.

The HHS claims implementation team recommended, and we are proposing for adoption, the following standards as implemented through the appropriate implementation guides, data content and data conditions specifications, and data dictionary:

  • Health care claim and equivalent encounter:
    • Retail drug: NCPDP Telecommunication Claim version 3.2 or equivalent NCPDP Batch Standard Version 1.0
    • Dental claim: ASC X12N 837 - Health Care Claim: Dental
    • Professional claim: ASC X12N 837 - Health Care Claim: Professional
    • Institutional claim: ASC X12N 837 - Health Care Claim: Institutional
  • Health care payment and remittance advice: ASC X12N 835 - Health Care Payment/Advice
  • Coordination of benefits:
    • Retail drug: NCPDP Telecommunication Standard Format version 3.2 or equivalent NCPDP Batch Standard Version 1.0
    • Dental claim: ASC X12N 837 - Health Care Claim: Dental
    • Professional claim: ASC X12N 837 - Health Care Claim: Professional
    • Institutional claim: ASC X12N 837 - Health Care Claim: Institutional
  • Health claim status: ASC X12N 276/277 - Health Care Claim Status Request and Response
  • Enrollment and disenrollment in a health plan: ASC X12 834 - Benefit Enrollment and Maintenance
  • Eligibility for a health plan: ASC X12N 270/271 - Health Care Eligibility Benefit Inquiry and Response
  • Health plan premium payments: ASC X12 820 - Payment Order/Remittance Advice
  • Referral certification and authorization: ASC X12N 278 - Health Care Services Review - Request for Review and Response

We chose version 4010 of X12 for each ASC X12N transaction. Later in this proposed rule is a list of candidates for most transactions. The ASC X12N transactions listed as candidate standards in this section were originally specified as version 3070 because at the time of HISB inventory version 3070 was the most current DSTU version. However, we are proposing that version 4010 would be proposed in lieu of version 3070 for the following reasons:

  • Version 4010 is millennium ready
  • Version 4010 allows for up-to-date changes to be incorporated into the standards.

We will propose a claims attachment standard in a separate document as the statute gives the Secretary an additional year to designate this standard. The attachment standards are likely to be drafted so that health care providers using Health Level 7 (HL7) for their in-house clinical systems would be able to send HL7 clinical data to health plans. Anyone wishing to use the HL7 may want to consider a translator that supports the administrative transactions proposed in this proposed rule and the HL7.

We will also propose a standard for first report of injury transactions in a later rule for reasons explained in depth under section II.E.9.