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Technical Documentation

CMS has prepared a comparison of the current X12 HIPAA EDI standards (Version 4010/4010A1) with Version 5010 and the NCPDP EDI standards Version 5.1 to D.0. The 4010A1 Implementation Guides and the 5010 Technical Report 3 (TR3) documents served as reference materials during the preparation of the comparison excel spreadsheets. The Data Interchange Standards Association(DISA) holds a copyright on the TR3 documents: Copyright (c) 2009, Data Interchange Standards Association on behalf of ASC X12. Format (c) 2009, Washington Publishing Company. All Rights Reserved. The TR3 documents can be obtained by clicking on the link in the "Related Links Outside CMS" section below.

CMS is making the side-by-side comparison documents available to interested parties without guarantee and without cost. The documents are available for download in both Microsoft Excel and PDF formats. The comparisons were performed for Medicare Fee-for-Service business use and while they may serve other uses, CMS does not offer to maintain for purposes other than Medicare Fee-for-Service. Maintenance will be performed without notification, as needed to support Medicare Fee-for-Service.

Commercial EDI Translators will perform the following editing / validation of EDI submissions:

EDI syntax integrity validation

  1. Valid Segments (e.g. valid segment identifier, number of elements, delimiters)
  2. Segment order (as defined by the X12 / NCPDP standard)
  3. Element Attributes (e.g. X12 usage, repetitions, data type, and min/max size)
  4. Numeric element validation (e.g. leading minus signs, decimal points for R data types)
  5. X12 / NCPDP syntactical rules

HIPAA syntax integrity validation based upon adopted specifications (X12 / NCPDP)

  1. Repeat maximums for segments, loops, elements (when repeating element are used)
  2. Used and un-used qualifiers, (internal) codes, elements, and segments
  3. Intra-segment situational data elements (e.g. DTP for auto accident becomes required when CLM011-1 or CLM11-2 is "AA" or "OA") 

Note: This does not include validation of external code sources (to be validated in the CEM).

Commercial EDI translators must refer to the Edits Spreadsheet to determine what action to take relative to syntax integrity compliance errors. If no reference is found in the Edits Spreadsheet for the compliance error the transaction set should be rejected with a 999R. These rejections should be tracked for potential inclusion within the Edits Spreadsheet,

Numeric and Decimal Data Type Elements

In the definition of the transaction flat file, each numeric or decimal data type element will have both an alphanumeric picture clause (e.g. PIC X(18)) and a redefined numeric picture clause (e.g. PIC S9(8)V99). If the numeric picture clause is shorter than the alphanumeric picture clause a filler field will be used to fill the balance of the field length.

Commercial EDI Translators will initialize the alphanumeric picture clause with spaces in the flat file. During EDI translation of numeric or decimal data elements the flat file field will be zero fill and justify the numeric value appropriately for the associated numeric picture clause. By doing so the CEM will be able to determine if the data element was not present (space filled) or when it was present with the correct value (zero filled).

e.g. CLM02 Total Submitted Charges

05 CLM02-TOTAL-SUBMITTED-CHARGES-GROUP PIC X(18).

05 CLM02-TOTAL-SUBMITTED-CHARGES-REDEF REDEFINES CLM02-TOTAL-SUBMITTED-CHARGES-GROUP.
10 CLM02-TOTAL-SUBMITTED-CHARGES PIC S9(8)V99.
10 CLM02-TOTAL-SUBMITTED-CHARGES-FILLER PIC X(8).

If alternative formats of the side-by-side comparison documents are needed, please use the "Submit Feedback" feature at the bottom of this page.