X12 Pilot plan
wedi.org
Transactions and Code Sets
Sequencing Proposal
Objective
The purpose of this proposal is to establish industry priorities and provide a framework for an orderly
transition to implementation of the HIPAA ANSI ASC X12N Transactions and Code Sets Standards as
defined in the final rule dated August 17, 2000.
HIPAA Transactions
837 – Health Care Claim or Encounter
835 - Health Care Claim Payment/Remittance
270 – Health Insurance Eligibility request verification for covered benefits
271 – Health Insurance Eligibility response verification for covered benefits
834 – Enrollment/Dis-enrollment to a health plan
276 – Health Care Claim inquiry to request the status of a claim
277 - Health Care Claim response to report the status of a claim
278 – Health Care Services, to request authorizations and referrals
820 - Premium Payment, for enrolled health plan members
Transaction Groups – this schedule will implement the transactions in a step by step sequence. The
sequencing allows the industry time to implement and test one or a few transactions at a time. We've
called these steps group 1 through group 5, because in some cases we're implementing more than one
transaction in the step, due to inter-transaction relationships. For example, the claim and claim
payment transactions are grouped together, because these two transactions will depend on data
requirements from the other.
The proposal identifies three significant implementation timeframes with staggered dates for the different
transaction groups.
Implementation Phases
1. Beta/Pilot Testing - the date when organizations should plan to begin beta/pilot
testing of their system/application enhancements required to reach a state of readiness to
process HIPAA transactions. This testing would involve the transferring transactions
between two covered entities. Vendor software is available and covered entities have
already completed internal system testing. During this time, a health plan would conduct
beta/pilot testing with a few selected providers/employers to verify their systems work
properly with other external entities.
2. Health Plan Readiness – For each transaction group, these are the dates when a
Health Plan to begin accepting production HIPAA transactions from willing trading
partners, this assumes their beta/pilot testing is completed. This will begin the transition
process, moving providers from the old formats to the new X12 transactions. During this
phase, prior to accepting transactions in production, each trading partner would be
expected to perform some initial testing to verify each entity is sending and receiving
transactions properly. Also, during this time health plans will continue to support current
processes, until the transition is complete for all their customers. Current processes
would include any proprietary formats, standards (e.g., UB92 Flat File, NSF) or older
versions of the X12 transactions. Health Plans should not require providers to submit
HIPAA compliant transactions prior to this timeframe.
3. Migration Completion - the point in time when all covered entities must complete
their conversion to the HIPAA transaction standards. This date, October 16, 2002,
corresponds to the 2-year mandate set forth in the HIPAA Final Rule for Transactions and
Code Sets.
Deployment Sequence and Implementation Schedule Table
Phases
Group 1
Group 2
Group 3
Group 4
Group 5
Transactions
Included with
each Group
837
835
270/271
834
276/277
278
820
Beta/Pilot
Testing Start
Dates
Jul 1, 2001
Dec 1, 2001
Feb 1, 2002
Mar 1, 2002
May 1, 2002
Health Plan
Readiness
Start Dates
Oct 1, 2001
Mar 1, 2002
May 1, 2002
June 1, 2002
Aug 1, 2002
Migration
Completion
Date
Oct 16, 2002
Oct 16, 2002
Oct 16, 2002
Oct 16, 2002
Oct 16, 2002
Pharmacy Transactions – still under discussion
Transaction Sequencing Decision-Making Rationale
The WEDI SNIP Transactions - Sequencing Workgroup considered the following factors when
developing the transaction sequence and schedule.
1. The 26- month implementation requirement is a short time period to implement all the transactions
with minimal cushion time between transaction groups.
2. Current industry implementation experiences with the transactions. It will probably take longer to
convert existing trading partners that already have electronic implementations either X12 or other
standards (e.g., UB92 and NSF). For this reason, the largely implemented transactions have been
placed early in the sequence
3. Development time needed for transactions not largely in use today coupled with less time needed for
deployment for existing implementations. For these reasons transactions have been placed closer to
the end of the implementation window.
4. Logical integration of business processes and data flows.
5. Inter-transaction dependencies related to data content and code sets (e.g., J codes to NDC codes,
type of service, taxonomy codes for specialty codes, claim status codes, anesthesia qualifier).
6. Transaction complexity. It may take longer to implement more complex transactions (i.e., claims)
therefore they were placed early.
7. Some transactions will have a positive impact on providers, reducing costs, improving efficiency, and
improving core business processing. This coupled with what is believed to be a relatively easy
development and implementation led to the decision to deploy the 270/271 transactions early in the
schedule.
8. Pilot availability due to mission-critical business events (i.e., open enrollment for health plans) led to
early an early deployment of the 834 transaction.
9. NCHICA and UHIN sequence and schedule.
10. State regulations (e.g., NJ HINT).
Related Documentation
The AFEHCT White Papers were used as the basis for the proposal and are available on the web
site afehct.org.
Transaction – Sequencing Workgroup Meeting Minutes
Remaining Issues
At the time of the release of this document, a number of issues remained open for further discussion
and collaboration within the WEDI SNIP Transactions Work Group. Following is a list of these issues,
and our plans for discussion with the Sub-Work Groups (SWG’s) of this Work Group.
1. The use of NDC Codes replacing the HCPCS J-Codes created a significant obstacle for the work
group to overcome while developing this schedule. This issue will have an impact on inter-transaction
dependencies and paper forms. The problem is further exacerbated by translation issues, which are
discussed below in item 2. WEDI SNIP will continue to address this issue within the Business Issues
SWG, but would like to re-emphasize the WEDI recommendation that the use of NDC codes be limited
to retail pharmacies, and not be required on other HIPAA transactions.
2. There are some concerns that converting to the new clinical code sets at the same time an entity
converts to the X12 transaction may not be possible. The issue is that during the transition this
approach may introduce problems that will be difficult to resolve; namely, that J-codes and some of the
local code changes will not translate easily between the HCPCS used today and the new national code
sets replacing them. Specifically, there are instances where the new national code sets will have several
equivalent codes to one HCPCS code. While the transition from the current transaction to the new
transactions occurs, not all transactions will be implemented for a provider or a health plan at the same
time. Therefore, the new code sets can’t be utilized for those transactions not yet converted; leaving the
requirement to be able to translate back and forth, from old to new code sets, between the different
transactions (e.g., claims vs authorizations). This could prove to be unsupportable if we can’t find a
one-to-one mapping between the old and new code sets.
The Translations and the Business Issues SWG’s will work on this and similar translation
issues. If a crosswalk can be developed and agreed to by the industry between the old
and new code sets, then we believe we can resolve the issue. However, if a crosswalk
can’t be developed, then this may need to be revisited and code sets may need to be
implemented as their own group at the end of the schedule.
Instructions for Submitting Comments:
There will be an open comment period on this proposal during the month of November 2000. To
comment, please go to the WEDI SNIP Web-site and enter the Issue Discussion Forum, where you’ll
be able to read other comments and enter a new comment if desired to this issue – Proposed
Deployment Sequence / Implementation Schedule.
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