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Back  RFI # 27: HL LOOP STRUCTURE IN TS 837

Formal vs. Informal Help Informal Formal

Submitter

Todd Cochrane

Description

In your correspondence you referenced version 004010X098A1 837 Health Care Claim Professional (Addenda). You also included an attachment that detailed two data sequence options related to an HL loop structure within TS837 as follows: OPTION 1: HL, SBR, --CLM, ----LX1, ----LX2, -PAT (dependant for SBR above), --CLM, ----LX1, ----LX2 OPTION 2: HL, SBR, --CLM, ----LX1, ----LX2, SBR (same SBR info as above), --PAT, --CLM, ----LX1, ----LX2 You asked these questions related to the two options: 1. Are both of these options syntactically correct X12 structures for claims that include services for both the subscriber and dependent? 2. If either or both of these two options are incorrect, how would a receiver of the transaction respond?

Response

The X12.6 Standard provides specific syntactic and semantic constraints on segment sequences and on hierarchical data structure sequences. The X12 Transaction Set 837 Health Care Claim defines the specific segment sequence structure of the Health Care Claim, and provides the semantic interpretation of data that complies with valid instances of the transaction set. The X12.22 HL Segment defines the purpose, the data content of the HL segment, and its semantic intent. The X12.3 Data Dictionary defines the purpose and content of data elements used in the HL segment, and their semantic intent. This interpretation applies to Release 010 of Version 004 of the referenced X12 Standards. This official interpretation does not reference the Implementation Guide cited in your letter, as that Guide is not an X12 Standard. However, following the official interpretation in this response letter is a discussion that does reference that Implementation Guide.

Recommendation

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Subcommittee X12C has reviewed the two instance options detailed in your attachment, and finds that both instances comply with X12.6 syntax rules. Subcommittee X12C also reviewed the X12.22 Segment Directory definition for the HL segment, and the X12.3 Data Dictionary for the data elements used in the HL segment, and found no violation of syntactic constraints in either instance option. Whereas X12J is responsible for development and maintenance of the HL segment; and whereas X12N is responsible for development and maintenance of TS 837 Health Care Claim; and whereas ordering of data may have semantic significance; X12C defers to X12J and X12N for the further interpretation of the issues raised in your request. Subcommittee X12N Insurance is responsible for the development and maintenance of TS 837 Health Care Claim. Subcommittee N has reviewed the two instance options detailed in your attachment, and finds that both instances comply with the semantic structure of TS 837 and both convey the same semantic information. Therefore, either option is valid for representing a claim. The official interpretation is based upon the referenced X12 Standards. The X12.1 TS 837 Health Care Claim Transaction Set defines the structure of the Health Care Claim transaction set, which was developed to convey health care claim data in a manner that preserved semantic intent. The X040010X098A1 Health Care Claim Professional (Addenda) Implementation Guide further constrains the data that may appear within an X12 TS 837 transaction set instance, and provides more detailed instruction on properly representing health care claim data in a manner that properly conveys the intended semantic meaning associated with that data. The X12 Standards provide a means to reference specific Implementation Guides (via the Version/Release/Industry Identifier Code). A transaction set instance that references an implementation guide via an Industry Identifier must also conform to that implementation guide.
Submission 1/1/2004
Status Date 1/1/2004
Status F - Final
Primary References
Document 4010 X098A1