X12 Technical Reports - Type 3

This 997 implementation guide can NOT be used for responding to any implementation guideline (TR3).

This 997 implementation guide can NOT be used for any application level validations.

• Send a health care fee schedule from a health plan to a provider

• To assist those who send additional supporting information or who receive additional supporting information to a health care claim or encounter.

• To assist those who send additional supporting information or who receive additional supporting information to a health care claim services review.

• Provide account activity values from insurers to distributors for statement consolidation and on-line updates.

• Provide account activity values from insurers to distributors for statement consolidation and on-line updates in a clearinghouse environment.

• Provide the required information, such as applicant name, address, beneficiary, and product name of annuity plan, to apply to purchase an annuity product

• Provide transaction-based compensation detail
• Provide asset or gross premium compensation detail at a point in time commission

• Provide transaction-based compensation detail
• Provide asset or gross premium compensation detail at a point in time commission

• To report errors that are outside of the scope of the ANSI ASC X12 997 or 999 error reporting
• To report the results of an application system's data content edits of transaction sets.

• Send billing information for automobile glass from vendors to insurance companies

• For insurers to provide electronic work assignments to automobile glass vendors

• Notification to state agencies within the U.S. of insurance coverage on a motor vehicle

• Notification of changes in financial interest on auto property records
• Notification of auto property record change errors

• Provide administrative detail information for the assignment and acknowledgment of the receipt of the assignment to dispose of the salvage vehicle

• Transmit subrogation demands and responses between insurers and third party administrators.

• Transfer enrollment information from the sponsor of insurance coverage, benefits, or policy to a payer.

• To provide premium billing information on property and casualty insurance coverage to consumer scervice providers (CSP)
• To provide preminum billing information on life insurance coverage and annuity contracts to CSPs
• To communicate errors or acceptance on premium billing information from the CSP to the insurance company

• To satisfy medical providers jurisdictional reporting requirements

• Payer to payer coordination of benefits verification request and response

• Provide claim status information from the payer without health care provider solicitation. For example, acknowledgment of a health care claim transmission.

• Make payment on a health care claim
• Send an Explanation of Benefits (EOB) remittance advice
• Make payment and send an EOB in the same transaction

• Provide claim status information on claims pending in the payer's adjudication system without requiring health care provider solicitation.

• Request the status of health care claim(s) and respond with information regarding the specified claim(s).

• Submit and transfer dental claims and encounters from health care providers to health care payers

• Submit and transfer institutional claims and encounters from health care providers to health care payers and between payers

• Submit and transfer professional claims and encounters from health care providers to health care payers and between payers

• Determine if an Information Source organization, such as an insurance company, has a particular subscriber or dependent on file
• Determine the details of health care eligibility and/or benefit information

• Provide claim status information from the payer without health care provider solicitation

Examples of these types of claim status notifications include acknowledgments of claim transmission.

• Transmit provider directory information

• Request and respond to requests for enumeration and/or participation in a network, as well as to update provider information

• Reporting health care service data for use in health data statistical analysis from provider data
• Reporting health care service data to satisfy governmental mandates necessary to regulate the health care industry
• Reporting health care service data to measure utilization rates

• Health care admission certificate requests and responses
Referral requests and responses
• Health care services certification requests and responses
• Extend certification requests and responses
• Certification appeal requests and responses

• Health care admission certificate requests and responses
• Referral requests and responses
• Health care services certification requests and responses
• Extend certification requests and responses
• Certification appeal requests and responses

• Make inquiries to utilization management organizations for information on previously processed health care services
• Send response(s) to inquiry(ies) on previously processed health care services

Notification of interested parties concerning events related to a health care services review such as:

• Patient arrival notice
• Patient discharge notice
• Patient transfer notice
• Notification of certification to primary care physcian (PCP), utilization management organization (UMO), or other service providers
• Certification notice change

• the transfer of enrollment information between Health Insurance Exchanges and Issuers.
• the reconciliation of enrollment information between Health Insurance Exchanges and Issuers.

• To report errors that are outside of the scope of the ANSI ASC X12 997 error reporting
• To acknowledge receipt of an error-free transaction

• To report errors that are outside of the scope of the ANSI ASC X12 997 error reporting
• To acknowledge receipt of an error-free transaction

• Report the results of inspection reports to satisfy insurance underwriting requirements for individually underwritten life, disability income, and health insurance and property & casualty insurance

Inspection reports include such investigations as credit checks, lifestyle/behavior, and tax history.

• To report results of MVR to trading partners for the individual underwriting process.

• To support interactive submittal and response of health care claim or encounters for the point of sale environment.

• Inquire on an individual's health care eligibility and coverage in an interactive mode (IHCEBI)
• Respond to a request for information on an individual's health care eligibility and coverage in an interactive mode (IHCEBR)

The IHCEBI identifies the patient in question, the insurance subscriber, and the provider or orgainization requesting the information. The IHCEBR provides the plan coverage information, patient/subscriber identifiers, coverage benefits, and third party liability information.

• Report the results of laboratory testing reports to satisfy insurance underwriting requirements for individually underwritten life, disability income, and health insurance

• Notification of mortgage record changes to financial interest entities
• Notification of mortgage record change errors

• Notification of insurance coverage for loans on motor vehicles
• Notification of insurance coverage for leases on motor vehicles

• Report the results of paramedical examination testing to satisfy insurance underwriting requirements for individually underwritten life, disability income, and health insurance

• Transmit payroll deducted premiums for a wide variety of insurance products, to include life, health, property and casualty, and disability.

This guide was also designed for health care premium payments between federal and state governments, government agencies, and private industry.

• To transfer Personal Health Record (PHR) information between different health plans.

• When an employer or coverage sponsor changes from one health plan to another, the new health plan may request the prior plan to transfer PHR information of those covered individuals
• When an individual changes jobs and elects coverage under a new health plan, they may request the transfer of PHR information for covered individuals. The prior health plan, with the individual's authorization, will transfer the PHR information to the new health plan.
• When an individual or subgroup of individuals changes from one health plan to another, the new health plan may request the prior health plan to transfer the PHR information of those covered individuals.

• to satisfy state and federal reporting requirements such as; Medicare and Medicaid encounters, All Payer Claims Databases, and Health Care Insurance Exchanges
• for use in health data analysis from payer data

• to satisfy state and federal reporting requirements such as; Medicare and Medicaid encounters, All Payer Claims Databases, and Health Care Insurance Exchanges
• for use in health data analysis from payer data

• to satisfy state and federal reporting requirements such as; Medicare and Medicaid encounters, All Payer Claims Databases, and Health Care Insurance Exchanges
• for use in health data analysis from payer data

• To support the financial reconciliation of a property & casualty, auditable policy premium paid to actual risk at the expiration of the policy

The insurance company uses the 187 to audit the claims experience of a policy at the time of its expiration or termination.

• Transmit health care claims and billing information from payers, such as insurers and employers, to regulatory agencies to monitor the rendering, billing, and/or payment of health care services related to property and Casualty medical losses.
• Collect data about property and casualty billings for regulatory agencies to perform statistical analysis

• Request automobile reservations
• Confirm automobile reservations
• Update automobile reservations

• To send invoice information from the rental company to the appropriate insurance company for vehicle replacement
• To perform error processing, if required, on the business transaction between the insurer and the rental company

The vehicle rental company uses the 810 to send invoice information, such as the rental charge, to the responsible insurance company for the replacement of a vehicle. The 824 is used to handle error processing that might occur with this electronic business transaction.

• To send payment information from the insurance company to the rental company on rental invoices for vehicle replacement

The insurance company uses the 820 to send payment information to the rental company on the rental invoices for the replacement of a vehicle. The 820 may be included as addenda records with an ACH (CTX) electronic payment transaction originated by the insurance company to the rental company's financial institution. The 820 may be sent separately from the funds as well. The 824 is used to handle error processing.

• Request that existing medical information related to a claim for disability benefits or workers' compensation benefits be sent from an information source, such as a medical provider, to a payer or payer's agent, such as a disability determination organization, for the purpose of supporting a claim for disability benefits or workers' compensation benefits or other related determinations.
• Request that a medical provider perform a service and transmit reports of that service to an information receiver, such as a payer or disability determination organization, for the purpose of supporting a claim for disability benefits or workers' compensation benefits or other related determinations.
• Request further information or report about the status of a previous request for medical information and reports in support of a Disability or Wrokers' Compensation claim.

• Notification to state agencies in the U.S. of insurance coverage for motor vehicles and certification to state agencies in the U.S. of insurance coverage for an individual.

• To notify state agencies about future proof of liability insurance (SR22, SR1P, SR23)

With this notification to a state agency, the insurer guarantees that the liability insurance on the automobile(s) will be inforce for a specified period of time and that coverage will be provided until the insurance company files a cancellation notice (SR26) with the state agency.

• Capitation payment detail
• Membership list
• Plan (coverages)
• Group (employer)
• Provider

• Provide automobile collision industry digital images, such as a photograph of a car in an imaged format

• For insurers to send payments/remittance advice information.

• Provide insurance carriers with information needed to determine the total loss value of a vehicle.