Questions Submitted by the Public, by Date Posted to the Website. Restricting data to that necessary for adjudication


Section 1.3 of the X12N 837 Professional Implementation Guide (IG) mentions that payers may create subsets to the guide within trading partner agreements and that payers are not required to bring data they cannot / prefer not to accept, into their adjudication system. Trading partners could then send transactions without that data and know the payer has agreed to accept and process the transaction without that data. The example given in the IG relates to home health data, the usage of which is situational.

Is it also correct to interpret this to mean that covered entities may therefore agree to transmit only data they deem necessary regardless of whether or not the data element is required or situational within the IG?

As an example, if a payer determines that they do not require the service facility address and that they will not be taking that data into their adjudication system, may they add a subset IG to their trading partner agreements indicating this data is not required? Or since section 1.1.1 of the same IG states that trading partner agreements may not modify the definition, condition, or use of a data element or segment in the standard IG, would the payer be required to maintain that required usage in the subset?


Health plans are required to be able to accept all of the data content included in the implementation guide (IG). They must be able to accept the data, but they do not have to process the data. Trading partner agreements may not change the definition, data condition, or use of a data element or segment in an implementation guide. If the element is defined as required, it must always be included in the standard transaction.

The subset to the IG referred to in section 1.3 of the professional 837 IG refers to data clarifications that may supplement the IG. Clarifications could include identifiers to use when a national standard has not been adopted, parameters in the IG that provide options, such as the number of claims to submit in a X12N 837 health care claim transaction or identifying elements that you will accept but will not process. Section 162.915 of the final rule sets the boundaries for trading partner agreements.