Health Care Claims or Equivalent Encounter Information for Professional Claims

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Federally required	Cost	Test Tool Availability
Implementation Specification	ASC X12®N/005010X222 Health Care Claim: Professional (837), May 2006 as an ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 and ASC X12N/005010X222A1 Type 1 Errata to Health Care Claim: Professional (837), June 2010 as Type 1 Errata to an ASC X12 Standards for Electronic Data Interchange Technical Report Type 3	Final	Production	Yes	$	Yes
Implementation Specification	HL7® FHIR® Consumer Directed Payer Data Exchange (CARIN IG for BlueButton®) STU 1	Final	Production	Yes	Free	Yes
Implementation Specification	HL7 FHIR Consumer Directed Payer Data Exchange (CARIN IG for BlueButton) STU 2	Balloted Draft	Pilot	Yes	Free	Yes

Limitations, Dependencies, and Preconditions for Consideration	Applicable Security Patterns for Consideration
The Administrative Simplification provisions of HIPAA apply to the adoption of electronic transaction standards and operating rules for use in the health care industry. Information about the HIPAA regulations regarding standards and operating rules can be found at https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/index.html. Readers can find information about requirements for covered entities and their business associates and enforcement from this link. This standard and the transaction were adopted under the Health Insurance Portability Act of 1996 (HIPAA) to increase efficiency in the health care system by reducing the use of paper and increasing the exchange of health care information electronically. The current version was adopted in 2009 and required for use in 2012. Content from the transactions is often maintained in provider practice management and billing systems but duplicates information in electronic health records. Before implementation of a new version of a standard, end to end testing should be conducted with vendor systems and between trading partners to ensure changes have been accommodated. Additional information is available on testing, and the full cost on any of the X12 transactions. ASETT is the HHS compliance tool to enable testing and complaint filing for all X12 and NCPDP® transactions. Information about the CMS May 2020 Interoperability and Patient Access final rule and the implementation guides recommended to comply with the FHIR based APIs included in that rule may be found on the CMS Interoperability website. The HL7 FHIR Consumer Directed Payer Data Exchange (CARIN IG for BlueButton) STU 1 was recommended to comply with the Patient Access API requirement.	All covered entities and their business associates are required to comply with the HIPAA Privacy and Security Rules. Health and Human Services has partnered with the Office of the National Coordinator and the National Institutes of Standards and Technology to publish comprehensive guidance for Security specific to electronic protected health information. A self-assessment tool kit is available to support integrating privacy and security into practices.

Limitations, Dependencies, and Preconditions for Consideration

Applicable Security Patterns for Consideration

The Administrative Simplification provisions of HIPAA apply to the adoption of electronic transaction standards and operating rules for use in the health care industry. Information about the HIPAA regulations regarding standards and operating rules can be found at https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/index.html. Readers can find information about requirements for covered entities and their business associates and enforcement from this link.
This standard and the transaction were adopted under the Health Insurance Portability Act of 1996 (HIPAA) to increase efficiency in the health care system by reducing the use of paper and increasing the exchange of health care information electronically. The current version was adopted in 2009 and required for use in 2012. Content from the transactions is often maintained in provider practice management and billing systems but duplicates information in electronic health records.
Before implementation of a new version of a standard, end to end testing should be conducted with vendor systems and between trading partners to ensure changes have been accommodated.
Additional information is available on testing, and the full cost on any of the X12 transactions. ASETT is the HHS compliance tool to enable testing and complaint filing for all X12 and NCPDP® transactions.
Information about the CMS May 2020 Interoperability and Patient Access final rule and the implementation guides recommended to comply with the FHIR based APIs included in that rule may be found on the CMS Interoperability website. The HL7 FHIR Consumer Directed Payer Data Exchange (CARIN IG for BlueButton) STU 1 was recommended to comply with the Patient Access API requirement.

All covered entities and their business associates are required to comply with the HIPAA Privacy and Security Rules. Health and Human Services has partnered with the Office of the National Coordinator and the National Institutes of Standards and Technology to publish comprehensive guidance for Security specific to electronic protected health information. A self-assessment tool kit is available to support integrating privacy and security into practices.

Comment

Submitted by markaroberts85 on 2022-10-01

CARIN Alliance Comments on ISA

The CARIN Alliance, a multi-sector group of stakeholders requests that ONC update the Health Care Claims or Equivalent Encounter Information for Professional Claims and Institutional Claims in the ISA to include the latest information related to the HL7® FHIR® Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) Implementation Guide (IG). Please see the attached comment letter for additional details.

CARIN Alliance Comments on ISA 093022_1.pdf

Submitted by kwboone on 2017-11-20

The use of standards based…

The use of standards based on 30 year-old UN-EDIFACT based standards needs consideration. They work, but quite frankly, take a mountain of healthcare specific training to adopt. The payment industry needs to consider pilots for moving towards RESTFUL based APIs for payment based transactions across the board, in both batch and real-time formats. It takes 5-10 years simply to adopt a new version of these standards to change the width of some fields and accommodate new coding or identifier systems

Submitted by Brett Andriesen on 2017-12-13

CMS Response

CMS Response: We appreciate the feedback and look forward to receiving specific recommendations from industry for the use of alternative standards that enable the electronic exchange of health care information. The HIPAA regulations encourage pilots to test the use of alternative standards which meet the objectives of administrative simplification.

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Health Care Claims or Equivalent Encounter Information for Professional Claims

Comment

CARIN Alliance Comments on ISA

The use of standards based…

CMS Response

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