Chapter 1. Purpose and Business Information

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1.1 Implementation Purpose and Scope

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For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed to facilitate consistent implementation by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.

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This is the implementation guide for the ASC X12N Health Care Service: Data Reporting when reporting or receiving health care services data. This implementation guide provides standardized data requirements and content utilizing the 837 Health Care Claim transaction set standards. This guide is not intended to meet the needs of all health care services data reporting. It is intended to provide a standard implementation for reporting systems that currently utilize or are capable of utilizing and to be consistent with the 837 Health Care Claims transaction set standards. This implementation guide provides a definitive statement of what data translators must be able to handle in this version of the Health Care Service: Data Reporting guide.

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This implementation guide is intended to be compatible, but not compliant with the national data standards set out by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its associated rules. Although public agencies are technically exempt from HIPAA's transaction and code set regulations, unless they are health care providers or health plans. The covered entities (data suppliers) are not exempt and must comply. The industry claim transaction standard, while uniform, does not meet the broader uses of public agencies, thus local, state, and federal agencies have modified the standard to meet local needs. This has resulted in reporting variability across public agencies and challenges in multi-state reporting and collection of administrative data. This guide seeks to promote less variability by improving data comparability and data integrity across States.

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