The following are key organizations and regulations relating to healthcare EDI transaction standards.
Standards Development Organizations
Accredited Standards Committee X12 (ASC X12)
ASC X12 develops and maintains standards for electronic data interchange relating to business transactions. ASC X12N, the Insurance Subcommittee of ASC X12, develops and maintains standards for healthcare administrative transactions. ASC X12 is a named Designated Standards Maintenance Organization under HIPAA.
National Council for Prescription Drug Programs (NCPDP)
NCPDP maintains EDI standards for the retail pharmacy industry. NCPDP is a named Designated Standards Maintenance Organization under HIPAA.
Health Level 7 International (HL7)
HL7 develops and maintains standards primarily for the exchange, integration, sharing and retrieval of health information to support the clinical practice and management of health services, including standards for attachments. HL7 is a named Designated Standards Maintenance Organization under HIPAA.
NACHA-The Electronic Payments Association
NACHA develops and maintains standards and operating rules for financial transactions traveling over the Automated Clearing House (ACH) Network, including healthcare electronic funds transfer (EFT) transactions.
Data Content Committees
Dental Content Committee (DeCC)
DeCC maintains content for dental claims and addresses standard electronic transaction content on behalf of the dental sector. It is chaired by the American Dental Association (ADA). DeCC is a named Designated Standards Maintenance Organization under HIPAA.
National Uniform Billing Committee (NUBC)
NUBC maintains content for institutional electronic and paper claims. It is chaired by the American Hospital Association (AHA). NUBC is a named Designated Standards Maintenance Organization under HIPAA.
National Uniform Claims Committee (NUCC)
NUCC maintains content for professional electronic and paper claims. It is chaired by the American Medical Association (AMA). NUCC is a named Designated Standards Maintenance Organization under HIPAA.
Workgroup for Electronic Data Interchange (WEDI)
WEDI is a cross-industry coalition focusing on the use of electronic healthcare information exchange to improve healthcare information exchange, enhance quality of care, improve efficiency, and reduce costs of the American healthcare system. WEDI was named as an advisor to the Secretary of Health and Human Services on matters relating to transaction standards development.
• Change Healthcare Guidance on WEDI SNIP Types
National Committee on Vital and Health Statistics (NCVHS)
The NCVHS was established by Congress to serve as an advisory body to the Department of Health and Human Services (HHS) on issues relating to health care statistics, policy, and regulations. Among other activities not related to EDI transactions, NCVHS makes recommendations to HHS on potential regulatory actions surrounding mandated transactions and operating rules.
Transactions and Code Sets Regulation
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) required the Department of Health and Human Services (HHS) to adopt national standards for the Electronic Data Interchange of certain covered healthcare transactions.
Transactions and Code Sets Modification - Current
On January 16, 2009, HHS issued the Health Insurance Reform; Modifications to the Health Insurance Portability and Accountability Act (HIPAA) Electronic Transaction Standards Final Rule which modified the original Health Insurance Reform: Standards for Electronic Transactions; Announcement of Designated Standard Maintenance Organizations; Final Rule and Notice by adopting version 5010 of the ASC X12N transactions, version D.0 of the NCPDP Telecommunication Standard Implementation, version 1.2 of the NCPDP Batch Standard Implementation, and version 3.0 of the NCPDP Medicaid Pharmacy Subrogation standard.
The Final Rule established January 1, 2012 as the implementation deadline for the new versions. Two discretionary enforcement periods were announced: the first period extending from January 1, 2012 through March 31, 2012 and the second period extending from April 1, 2012 through June 30, 2012. The discretionary enforcement periods did not change the compliance date of the regulation – the enforcement delays simply stated that CMS would not enforce compliance.
Purchase the Standards on the ASC X12 Store
Transaction Standards Modification Version 7030™ - Anticipated
The ASC X12N Insurance Subcommittee is finalizing version 7030 of the both the mandated and voluntary healthcare Technical Reports Type 3 (TR3s). It is anticipated that ASC X12N will recommend that version 7030 of the mandated transaction standards be adopted under HIPAA.
The cycles for review and comment of the TR3s has been established by X12N and will be staggered into several overlapping cycles. See the home page of www.hipaasimplified.com for more information from Change Healthcare about the Public Review and Comment Period for the version 7030™ TR3s.
Timeline for the Comment Period
Online ASC X12 Public Review Forum
Transactions and Code Sets Rule – Original (Superseded)
To carry out the provisions of HIPAA, HHS published the Health Insurance Reform: Standards for Electronic Transactions; Announcement of Designated Standard Maintenance Organizations; Final Rule and Notice on August 17, 2000. This regulation named version 4010 of the following transactions as a HIPAA standard:
- ASC X12N Health Care Eligibility Benefit Inquiry and Response (270/271)
- ASC X12N Health Care Claim Status Request and Response (276/277)
- ASC X12N Health Care Claims: Professional (837P), Institutional (837I), Dental (837D)
- ASC X12N Health Care Claim Payment/Advice (835)
- ASC X12N Health Care Services Review – Request for Review and Response (278)
- ASC X12N Benefit Enrollment and Maintenance (834)
- ASC X12N Payroll Deducted and Other Group Premium Payment for Insurance Products (820)
- NCPDP Telecommunication Standard Implementation version 5.1
The implementation deadline for this regulation was October 16, 2003.
HHS published the Health Insurance Reform: Modifications to Electronic Data Transaction Standards and Code Sets Final Rule on February 20, 2003 which modified the original Transactions and Code Sets Final Rule by adopting errata versions of the named transactions.
Healthcare Electronic Funds Transfer (EFT) Rule
On January 10, 2012, HHS issued the Administrative Simplification: Adoption of Standards for Health Care Electronic Funds Transfers (EFTs) and Remittance Advice; Interim Final which established healthcare EFT standards for claim payments initiated over the Automated Clearing House (ACH) network.
- Adopted the Cash Concentration/Disbursement plus Addenda (CCD+) implementation specifications from the 2011 NACHA Operating Rules and Guidelines. The CCD+ format is also known as the Corporate Credit or Debit Entry.
- Adopted the implementation specifications from the ASC X12 Health Care Claim Payment/Advice (835) by requiring the TRN segment from the associated 835 be placed in field 3 of the CCD+ Addenda record.
The Interim Final Rule established January 1, 2014 as the compliance date.
NCPDP Script Rule
On November 16, 2012, the Centers for Medicare & Medicaid Services (CMS) issued the Medicare Program: Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013; Final Rule which adopted NCPDP SCRIPT version 10.6 as the official Medicare Part D e-prescribing standard as of November 1, 2013, retiring SCRIPT version 8.1 as an allowable e-prescribing standard.
- Benefit Enrollment
- Claim Status
- Claims / Encounters
- Eligibility / Benefits
- ERA / EFT
- Payroll Deducted and Other Group Premium Payment
- Referral / Priority Authorization