EDI 101 IAIABC Basic Concepts of EDI 2008 IAIABC All-Committee Conference April 7, 2008 Austin, TX IAIABC Website: iaia

1. EDI 101IAIABC Basic Concepts of EDI2008 IAIABC All-Committee ConferenceApril 7, 2008Austin, TXIAIABC Website:http://www.iaiabc.org

2. EDI 101: The Basics Presented by: • Gayle Parrish, EDI Coordinator, Oregon Workers’ Comp. Division • Faith Howe, IAIABC EDI Manager Class Intros.Name, organization, and what do you want to learn today?

3. Web Resources & Email Addresses • http://www.iaiabc.org • http://discussion2.iland.com/~jbaxter • http://www.wcio.org • http://aspe.os.dhhs.gov/admnsimp • gayle.m.parrish@state.or.us • fhowe@iaiabc.org

4. EDI Training Overview EDI 101 The Basics How EDI works Implementation Guides Proof of Coverage 201 WCPOLS to IAIABC Transaction Sequencing Requirements Analysis Claims 201 Report Triggers Transaction Sequencing Processing Options Medical 201 Reporting Basics Introduction to ANSI The Imp. Guide Systems 301 Technical Issues File Layouts Acknowledgments

5. Why standards? What is “EDI”? What does EDI data look like? Hitchhiker’s Guide to EDI 101 Electronic Reporting EDI 101 A49 PC2 148 PC1

6. How does EDI work? Hitchhiker’s Guide to EDI 101 EDI 101 EDI

7. What is an Implementation Guide? Claims Proof of Coverage Medical Hitchhiker’s Guide to EDI 101 EDI 101

8. EDI Where do I find the Implementation Guides? Hitchhiker’s Guide to EDI 101 EDI 101 Who is doing EDI? Other fun and exciting stuff . . .

9. What does ‘EDI’ mean? • Electronic – means sent via electrons, “computer stuff” • Data – means that we are concerned with the information, rather than the format • Interchange – means that there’s a two-way ‘conversation’ going on

10. IAIABC EDI Project History • Multi-state carriers, TPAs, self-insureds and other parties raised the issue of proprietary/nonstandard reporting requirements. • 1990, IAIABC membership adopted the IAIABC Statistics Committee’s proposal to develop standards for communicating data electronically between providers, payers and state administrators via EDI.

11. The “Old Days” Jurisdiction “A” Jurisdiction “B” ACME Ins. Jurisdiction “C”

12. Developing an Electronic StandardBringing Together the Right Participants Carriers Jurisdictions Vendors TPAs

13. EDI – a better way! Jurisdiction “B” Jurisdiction “A” ACME Ins. Jurisdiction “C”

14. Key Components of EDI • Standards (what’s in the package?) • Formats (what hauls the package?) • Communication (how does it get from here to there?) • Courage (who volunteered me?)

15. Standards (what’s in the package) Claims Coverage Medical Medical Bill Payment FROI PC1 Insured First Report of Injury PC2 Employer SROI Subsequent Report of Injury

16. Formats(what hauls the package) Flat File ANSI* XML* Basic, easy, computer-ready, one-size-fits-all Compressed format; needs to be “translated” Platform-independent, universal *American National Standards Institute *Extensible Markup Language

17. Communication(how does it get from here to there) Private Network built-in security World-Wide Web via Secure FTP or equivalent

18. Courage (why me?) • EDI means ‘new ways of doing business’ • New way of doing business means ‘change’ • Change means resistance (sometimes) and confusion (usually) – at least at first • Change is hard!

19. What does EDI data look like? Flat File • Basic format; no need to translate for machines to read • Location defines data (move everything one position off, and it’s ‘garbage’) • All unused spaces must be filled with spaces or zeroes • EXAMPLE: Jan_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Doe _ _ _ _ _ _ _ _ _ _ _ _ _ 081519510101

20. What does EDI data look like? ANSI • “Squeezes out” unused spaces to save transmission costs • Order defines data, so data must remain in same sequence; uses ‘special character’ to separate data fields and to account for missing fields • Requires “translation” to convert to flat file for processing • EXAMPLE: Jan*Doe*0815*19510101*

21. What will EDI data look like: XML • Developed as an Internet standard, so can be read by any machine that can ‘read’ HTTP* or by humans • Currently in development for claims reporting • Label defines data; position or sequence of fields don’t matter • EXAMPLE: <FirstName=‘Jan’> • <DateofBirth=‘19510101’> • <TimeofInjury=‘0815’> • <LastName=‘Doe’> *Hypertext Transfer Protocol

22. How is the data ‘packaged’?

23. EDI Transmission Components • A TRANSMISSION contains • One or more BATCHES, which contain • The HEADER • One or more TRANSACTIONS • The TRAILER

24. An EDI Transmission • Header • Transaction(s) • Trailer BATCH TRANSMISSION • Header • Transaction(s) • Trailer BATCH • Header • Transaction(s) • Trailer BATCH

25. EDI Batch Components • Header • One or more Transactions with one or more records in each • Coverage data; OR • Claim data (First OR Subsequent Rpt); OR • Medical data • Note: These data are never sent ‘mixed’ • Trailer

26. EDI Header • Sender ID: “Return Address” • Who is sending this data? • Receiver ID: “Address” • Who is this data being sent to? • Transaction Set ID: “Summary” • What kind of record is this (HD1, 148, etc.)? • Transmission: “Tracking Info.” • What date and time was it sent?

27. EDI Transactions • Claims:(flat file; R1.0 ANSI also) • 148: First Report of Injury (+companion) • A49: Subsequent Report of Injury (+companion) • Proof of Coverage: • PC1 Insured Record(s) • PC2 Employer Record(s) (flat file only) • Medical: • 837: Bill Payment Record (ANSI only)

28. EDI Trailer • Transaction Set ID: “Summary” • What kind of record is this (TR1, TR2)? • Detail Count: “How many?” • Did all the data arrive?

29. EDI Acknowledgment • Acknowledgment from Receiver • Transaction Set ID (match) • Acknowledgment Code (HD/TA/TE/TR) • Number of errors • Free-form text • Detailed error information • Element Number • Error Code • Variable Segment Number (if applicable)

30. “How to Build a Claim Batch” Release 1.0 Release 3.0 FROI SROI FROI SROI H H H H 148 A49 148 A49 R22 R21 ‘companion record’ 148 A49 A49 148 R22 T R21 T T T

31. “How to Build a POC/Medical Batch” Proof of Coverage Medical Bill H H PC1 837 PC2 837 PC2 837 PC1 837 PC2 T T Activity: File Building

32. A Quick Guide to the EDI Process Submission Identification Translation If necessary Edits Response Acknowledgment

33. Where to find it: A guide to the IAIABC Web Site(http://www.iaiabc.org)

34. Where’s the EDI section?

35. Who’s doing what?

36. Current State EDI Status

46. Break Time!

47. What Are the IAIABC Data Standards? • Claims Releases 1.0, 2.0, 3.0 • Proof of Coverage Releases 1.0, 2.0, 2.1 • Medical Release 1.0

48. CLAIMS

49. What is Claims Release 1.0? • Limited set of data elements, basic functionality, met the needs of states that were ready to implement EDI in 1995 • 23 States Mandating/Using Release 1.0 (see Progress Maps for details)

50. Why Claims Release 2.0? • Expanded Set of Data Elements • Significant Technical Format Changes • California no longer acceptsRelease 2.0 • Iowa currently Mandating Release 2.0 (but will migrate to Release 3.0) • Changes to R2.0 published standard are not allowed. New implementation is not supported.