What is ANSI EDI X12?
Just to put it simply - EDI X12 (Electronic Data Interchange) is a data format based on ASC (Accredited Standards Committee) X12 standards. It is used to exchange specific data between two or more trading partners. Term "trading partner" may represent organization, group of organizations or some other entity. In most cases it is just an organization or company. For Filopto this means a third party, insurance company or payor gateway provider that will process your claims and remit payments.
Deviations Are Standard?
While ANSI EDI X12 formats are based on the American National Standards Institute standards, in the real world there are many deviations from the standard. Some deviations are so prevalent they become defacto sub-standards in they own right.
One of the best examples is the HIPAA ANSI EDI X12 837 and 835 Healthcare Claim standard. Officially there is only one EDI X12 837 and 835. But due to very different requirements for institutional, dental and professional medical claims there are subsets for 837I, 837D and 837P. There is also probably a few hundred if not thousand variations of these. Many trading partners you might need to deal with will provide you with they own document called “Companion Guide”. These additional documents list specific requirements to they business needs and changes you must provide to the standard claim file before they can process it for payment.
In order to address these deviations, companies such as Accra Solutions Inc. must invest in various programs such as Map Editors, Mappers, Viewer tools, Mapping tools, Translators tools, x12 servers etc to accommodate the various changes to the programming that each trading partner requires. These tools allow for flexible customization and mapping of claims translation and validation rules to your specific requirements. In other word we need to adjust the "Standard Claim and Reimbursement file" to meet the unique changes required by each trading partner. Other HIPAA Claim related files that have a number of deviations are EDI X12 835 ( reimbursement), 834, 810, 850, 855. As a rule of thumb more complex the message structure is – more possible deviations exist in real world implementations. HIPAA likes to make things complicated.
What does it mean for your implementation? Why those deviations matter?
Let’s take 837 (Claim submission) as an example. It is important to understand that every EDI X12 837 is unique within the context of the trading partner. No two trading partners will want the same 837 Claim file. Yes, they are all based on the same standard 837. Yes, they are all targeted for specific sectors: 837P, 837I, 837D, and more etc. So you logically assume they are all identical. You are wrong! Each trading partners tweaks it for their own purposes and some even tweak it to accommodate a specific client, resulting in the standard, no longer being a standard, but rather a suggestion of what a claim file could look like.
If you take two EDI X12 837s claim files from two different trading partners chances are you will find at least a few different segments in each, for the file that Filopto has to send them. That means in most cases you need your specific 837 (claim submission) and 835 (claim reimbursement) files to include the specifics changes/addition/deletion for your chosen trading partner for your claims to be processed and paid.
Why do we charge for the ANSI X12 835 and 837 Claims connector?
The American National Standards Institute (http://www.x12.org/) that manages the ANSI X12 standards requires annual membership and yearly fees for the right to access and use the ANSI X12 Standard. In addition the need for the specialized tools required to manage the ANSI X12 format, the cost associated to create the unique connectors for your specific trading partner requirements is a cost that cannot be distributed between all Filopto clients.
If you require an ANSI X12 connector
If you require an ANSI X12 837 or 835 connector, Accra Solutions Inc. can provide you with the cost for developing the specialized connector for your specific trading partner. Please contact us for a quote.
