Health Care & Insurance

Health care and insurance activities including those undertaken by private, commercial, and government health care organization rely on X12's work. Several X12 implementation guides developed by the Insurance Subcommittee are mandated for the exchange of administrative and related information between trading partners, also known as covered entities under HIPAA. X12 also publishes and maintains several code lists that are referenced in its implementation guides but are external to them, known as external code lists.

Examples of common X12 Transaction Sets and Implementation Guides used in the health care and insurance industry include:

  • Health Care Eligibility/Benefit Inquiry and Information Response (270/271)
  • Health Care Claim: Professional, Institutional, and Dental (837)
  • Health Care Payment/Advice (835)
  • Transaction Sets: Motor Vehicle Insurance Coverage Notification (811)
  • Automobile Property Record Change Notification (266)
  • Mortgagee Notification, Billing, and Payment (811/820)

Examples of external code lists include:

  • Claim Adjustment Reason Codes
  • Claim Status Codes
  • Provider Adjustment Reason Codes
  • Property & Casualty Code Lists

Subcommittee: X12N

Available Resources

  • Design Rules & Guidelines
  • Control Standards
  • EDI Standard Transaction Sets
  • Implementation Guides
  • Reference Models
  • EDI Standard and Implementation Guide Table Data
  • EDI Standard and Implementation Guide XSDs
  • External Code Lists

Design Rules & Guidelines

The Design Rules and Guidelines assist standards developers of X12-syntax-based messages achieve consistent and technically appropriate transaction sets that meet the needs of the user community.

Sample - Design Rules and Guidelines

Control Standards

Control standards define all the basic syntax aspects of the X12 EDI Standard. Included are the Interchange, Application, Interconnect Mailbag, and Security Control Structures, as well as the Semantic Impact for implementation of EDI structures.

Sample - Interchange Control Structure

EDI Standard Transaction Sets

An X12 transaction set is a semantically meaningful unit of information exchanged between trading partners. A transaction set may consist of a transaction set header segment, security header segments, assurance header segments, one or more data segments and loop control segments in a specified order, one transaction security value segment for each assurance header present, one transaction security trailer segment for each security header segment present, and a transaction set trailer segment.

Sample - 275 Patient Information Transaction Set

Implementation Guides

An implementation guide is a technical report that addresses the use of one or more transaction sets for one specific business purpose in order to facilitate consistent transaction set implementation within an industry or sub-industry.

Each implementation guide is specific to one version of the EDI Standard.

X12 developed several implementation guides for the health insurance industry that are adopted under HIPAA for exchanging administrative data between health care payers, providers, and related organizations.

Additionally, X12 has published many related implementation guides for exchanging other types of information between trading partners, such as patient and additional information to support health care claims.

Sample - 008010X322 Health Care Claim Payment/Advice (835) Implementation Guide

Reference Models

Reference models describe related business processes, computer applications, or business data flows, and are intended to assist in system development. Examples include control structures and standards for handling acknowledgments, and how to create XML element names from X12 implementation guides.

Sample - Acknowledgment Reference Model

EDI Standard and Implementation Guide Table Data

Table data files are inert raw data intended to be imported into existing applications by software developers or implementers.

It is not intended to replace Implementation Guides, X12 Technical Reports, or the X12 Standard, but may be useful in saving considerable time compared to manually building and maintaining protocol to work with EDI toolsets, especially if you intend to handle several transaction sets and versions.

Sample - Implementation Guide Table Data readme.txt

EDI Standard and Implementation Guide XSDs

X12 XSDs are mechanically generated from the same database as the implementation guides and EDI standard. Both the TR3 and EDI schemas are W3C-compliant XML Schema Definition (XSD) files. Using X12's auto-generated XSDs saves considerable time compared to manually building and maintaining XSD.

Sample - 005010X221 Health Care Claim Payment/Advice (835) Implementation Guide XSD Schema

External Code Lists

External code lists, referenced in other X12 work are maintained by X12 and related organizations. They are published by WPC on their behalf, and are available for viewing online for free at https://x12.org/codes.

Viewing online is free at X12.org/codes and does not require a license, though embedding or redistributing the code lists in any form may require a license depending on the code list. Please contact licensing@x12.org for more information.