Section title: News

X12 Member Announcement: Recommendations to NCVHS - Set 1

Greetings X12 Member Representatives,

I'm pleased to let you know that today X12 submitted the first in a series of recommendations for advancing the version of our already mandated transactions and proposing additional transactions for adoption. This would not have been possible without the expertise, hard work, and diligent effort each of the X12N constituents contributed over the past few years. The standards development process is not always easy but the open-minded discussions that allow us to collaborate to consensus result in efficient and effective standards that we can all be proud of. On behalf of the X12 Board, the ASC officers, and the X12N officers, well-done and thank you.  

As discussed previously, based on industry feedback, X12 is using a phased approach for these recommendations rather than presenting the entire suite of recommendations at once. Each set of recommendations will include the most recent versions of a logically grouped collection of implementation guides. Each set will include supporting information targeted to specific healthcare stakeholders, including highlights of functionality enhancements, a high-level estimate of implementation costs, and other collateral to assist in the regulatory adoption process. More information is available on our website at This webpage will be updated regularly with updates and additional information.

The implementation guides in this set are X12's claim submission and remittance advice transaction sets including:

  • 008020X323 Health Care Claim: Professional (837)
  • 008020X324 Health Care Claim: Institutional (837)
  • 008020X325 Health Care Claim: Dental (837)
  • 008020X322 Health Care Claim Payment/Advice (835)

As you all know, there have been many discussions over the years related to the challenges of a lengthy Federal Rulemaking process that doesn't always operate at an expected cadence and the standards development organizations' continuously evolving standards. With this dichotomy in mind, X12 is proposing that the NCVHS evaluate version 008020 of the implementation guides listed below. If the NCVHS recommends the upgraded versions for adoption, we recommend the Center for Medicare & Medicaid Services (CMS) use the 008020 versions for the initial steps of the Federal Rulemaking process. When CMS is ready to issue a Notice of Proposed Rulemaking (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 or additional functionality that has been added between the 008020 version and the most recently published version of the implementation guides. CMS would then include the latest versions in the NPRM. This will ensure that the versions named in the NPRM and Final Rule processes reflect the most up-to-date requirements. Example of planned enhancements that will be valuable for the industry include:

  • Revisions to keep our instructions aligned with related NCPDP instructions
  • FHIR crosswalks that support consistent and reliable transitions between the syntaxes for implementers who want to support both syntaxes
  • Revisions based on lessons learned during the planned pilots
  • Revisions based on feedback from individuals and organizations that review the 008020 implementation guides during the NCVHS comment and hearing processes
  • Revisions that the X12N constituents identify as part of our normal maintenance activities

As each of the recommendations works its way through the federal processes, X12 will be working with its licensing partners to develop and implement pilot testing to prove the viability of the recommended transactions. Results of the pilot test use cases will be shared after each pilot is completed.

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 recommended both the 008020 EDI Standard representation (the implementation guide) and the XML representation be named as permitted syntaxes. As noted above, X12 intends to provide FHIR crosswalks in these implementation guides in time for inclusion in the Federal NRPM and Final Rule processes. These crosswalks support interoperability and allow covered entities to select the syntax that best meets their needs while ensuring the data consistency that is the bedrock of standardization. X12 will propose that the FHIR APIs be covered by a clause similar to the current Direct data entry accommodation that allows trading partners to utilize DDE systems so long as the data content complies with the data as defined in the associated X12 implementation guide.

At a high level, the 008020 versions of these implementation guides provide the following functional enhancements that improve claims and remittance processing across the health care industry.

  1. Including device identifier information on claims transactions greatly improves the industry's ability to identify risks and reach patients who may be affected by device failures. This improves patient outcomes and reduces patient health risks and enhances tracking and reporting related to specific devices. It also saves taxpayer funds.
  2. Explicitly supporting factoring agents' inclusion in the health care claim improves a provider's access to short-term capital which is important in today's healthcare environment.
  3. The number of entities handling claims during submission, acknowledgment, and response workflows has increased over the years, allowing for longer claim identifiers improves tracking, auditing, and matching functionality throughout the claim's life cycle. 
  4. Reducing manual processing related to recoupment handling improves efficiency and provides cost savings for both providers and payers.
  5. Including more detailed source of payment codes in remittances improves provider understanding of how their claims are adjudicated by payers, reducing the number of phone calls and other individual inquiries which reduces processing costs for all parties.
  6. Clarifying ambiguities by providing additional instructions and clearer wording in the implementation guides reduces inconsistencies, friction, and misunderstandings between trading partners.

In the coming weeks, X12 will be providing several change summary options online including a complete list of revisions, a list of revisions of particular interest to business analysts, and a list of revisions of particular interest to programmers. X12 will also be hosting a series of webinars and providing on-demand computer-based training materials that will assist implementers with their assessments of the updated implementation instructions included in the 008020 versions. 

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, we estimated the average costs as shown below.

Number of Enhancements 1,041 1,136 333 259
Implementation Guide Estimated Cost Average Cost per Enhancement
008020X323 Health Care Claim: Professional (837) $267K $256
008020X324 Health Care Claim: Institutional (837) $327K $288
008020X325 Health Care Claim: Dental (837) $222K $666
008020X322 Health Care Claim Payment/Advice (835) $318K $1,227

Most organizations will be applying these incremental changes to a stable, effective, and efficient EDI infrastructure in which they have already invested substantial capital. It's important to keep in mind that these costs will not be incurred by every covered entity. In many cases, a software vendor or clearinghouse will incur implementation costs that benefit their customer base. Additionally, many health care organizations will incur the implementation costs once, making the revisions and enhancements available to any number of subsidiary organizations, internal systems, and end-users.

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 submit feedback to the NCVHS.

Again, thanks to all of you who have made these recommendations possible. I look forward to seeing many of you soon at the Summer 2022 standing meeting in San Antonio, Texas.


Cathy Sheppard