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April 11, 2023
Jacki Monson, JD
Chair, National Committee on Vital and Health Statistics
c/o Rebecca Hines
NCVHS Executive Secretary
Dear Ms. Monson,
X12 is pleased to submit the next set of recommendations for advancing the version of already mandated transactions. The implementation guides in this set are listed below.
- 008030X329 Health Care Claim Status Request and Response (276/277)
- 008030X333 Benefit Enrollment and Maintenance (834)
- 008030X334 Payroll Deducted and Other Group Premium Payment for Insurance Products (820)
Each of the X12 implementation guides included in this recommendation has a corresponding XML schema definition (XSD) that supports the direct representation of the transaction using XML syntax. X12 mechanically produces these representations from the same metadata used to produce the implementation guide, ensuring there are no discrepancies between the syntaxes. X12 recommends both the 008030 EDI Standard representation (the implementation guide) and the XML representation be named as permitted syntaxes.
As with our first set of recommendations, X12 is proposing that the NCVHS evaluate version 008030 of the implementation guides included in this recommendation. If the NCVHS recommends the upgraded versions for adoption, we recommend the Center for Medicare & Medicaid Services (CMS) use the 008030 versions for the initial steps of the Federal Rulemaking process. When CMS is ready to issue a Notice of Proposed Rule Making (NPRM) to gather public feedback, X12 will identify the most recently published version of the implementation guides and provide a list of any substantive revisions between the 008030 versions and the most recently published version of the implementation guides. This will allow for revisions based on lessons learned during the planned pilot and other feedback from organizations reviewing the implementation guides during the NCVHS comment and hearing processes. If CMS names the latest versions in the NPRM it will ensure that the NPRM and Final Rule processes reflect the most up-to-date implementation instructions.
As the X12 recommendations work their way through the federal processes, X12 is teaming with a group of its licensing partners to develop and implement pilot testing to prove the viability of the recommended transactions. The pilot results will be publicly available.
As an aside, the Center for Consumer Information and Insurance Oversight (CCIIO) is currently using the 005010X220, the Health Care Benefits Enrollment and Maintenance (834) and the 005010X306 Health Insurance Exchange Related Payment (820) implementation guides to support of their EDI processes. We’ll be reaching out to them in the future to discuss the advantages of moving to the 008030X345 Health Insurance Exchange Related Payment (820) implementation guide.
The 008030 versions of these implementation guides provide the following enhancements that improve consistency and efficiency across the health care industry.
008030X329 Health Care Claim Status Request and Response 276/277
- Reduces ambiguity throughout the implementation guide
- Increases data synchronization with the claim transactions
- Adds the ability to report the status of predeterminations for medical and dental care
- Supports a property and casualty claim number when one applies
- Increases the number of service line procedure modifiers supported
- Supports tooth-level information on dental claim status responses
- Enhances the instructions for real-time vs batch processing
- Supports one information source and one information receiver per transaction
- Enhances the linkage between a 276 Request and a 277 Response
- Supports claim status when a claim has been transferred to another entity for processing
008030X333 Benefit Enrollment and Maintenance 834
- Reduces ambiguity throughout the implementation guide
- Adds Medicare-specific coverage begin and termination dates
- Supports the tracking of date/time for online applications
- Supports the Individual Taxpayer's Identification (ITIN)
- Enhances gender reporting *additional gender reporting enhancements are pending based on the cross-SDO Gender Harmony Project's recommendations
- Supports use of the Class of Race or Ethnicity from the CDC
- Supports reporting of pregnancy-related dates
- Supports tax advantage account information
- Enhances maintenance reason codes related to health coverage
008030X334 Payroll Deducted and Other Group Premium Payment for Insurance 820
- Reduces ambiguity throughout the implementation guide
- Enhances consistency between implementation guides
- Supports adjustments to a prior payment
- Enhances member-level information
- Adds member-level coverage information
- Supports reassociation of premium payments and enrollment transactions
Difference summary information is available on our website at X12.org/news-and-events/x12-recommendations-to-ncvhs. Various filters are available based on feedback from previous reviewers. In the second quarter of 2023, X12 will also begin rolling out a series of webinars and online training materials to assist implementers with their assessments of the updated implementation instructions.
As a part of the change summary preparation, X12 estimated the costs of implementing these versions based on the complexity of the enhancement, and whether business analysts, programmers, or both would need to assess the revisions. Using these calculations and estimated labor rates from reputable online hiring platforms, X12 estimates the average costs as shown below.
| Implementation Guide | Estimated Cost | Number of EnhancementsAverage Cost per Enhancement |
| 008030X329 Health Care Claim Status Request and Response (276/277) | $132K | 191$693 |
| 008030X333 Benefit Enrollment and Maintenance (834) | $15K | 189$682 |
| 008030X334 Payroll Deducted and Other Group Premium Payment for Insurance Products (820) | $46K | 67$682 |
Most organizations will be applying these incremental changes to a stable, effective, and efficient EDI infrastructure in which they have already invested substantial capital. In many cases, a software vendor or clearinghouse will incur implementation costs that benefit their customer base as opposed to each of their customers incurring separate implementation costs.
Per the requirement to consult with the organizations named as DSMOs in the HIPAA regulations, X12 has informed those organizations of this recommendation and requested that they review and provide feedback either directly to X12 or, more formally, to the NCVHS.
X12 looks forward to discussing this recommendation in more detail with the members of the NCVHS. In the meantime, please contact me if you need more information or have any questions about the information included in this recommendation.
Sincerely,
Cathy Sheppard
Cathy Sheppard
X12 CEO
csheppard@x12.org
| cc: | Rebecca Hines MHS, Designated Federal Officer Health Scientist, CDC/National Center for Health Statistics Office of Planning, Budget and Legislation vgh4@cdc.gov |
| Richard W. Landen MPH, MBA, Co-chair of the NCVHS Subcommittee on Standards RichLandon@aol.com |
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| Denise E. Love BSN, MBA, Co-chair of the NCVHS Subcommittee on Standards Dloveski@outlook.com |
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| Lorraine Tunis Doo MPH, Lead Staff to the Subcommittee on Standards Senior Policy Advisor, Health Informatics and Interoperability Group Office of Burden Reduction and Health Informatics (OBRHI) HHS/Centers for Medicare & Medicaid Services lorraine.doo@cms.hhs.gov |
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| Gary Beatty Accredited Standards Committee Chair ascchair@x12.org |