What is X12 Anyway?

By Nicole Fletcher,

At PokitDok, we talk the X12 talk all day, every day. From the water cooler and the coffee pot, to the conference room and beyond, we chat about data sets and payer integrations til the cows come home. We realize we're different though- so in the spirit of education and live application, we thought we'd take a minute to break down the specifics of this much beloved communication standard- and more importantly, why you should care.

First things first, what is X12?

X12 is an exchange standard (more on what this means later) for real data that is used by many industries - from finance and government, to transportation, healthcare and beyond. When we talk about X12 of course, we're talking about healthcare. When it comes to data type and uniformity, one might assume the data well - woke up like this - when in fact, it's a bit of a mess before its morning routine.


Screen Shot 2022-02-18 at 12.02.39 PM



Screen Shot 2022-02-18 at 12.03.16 PM


It takes some work to look this good.

What that means is that data comes in all shapes, sizes and languages - and in order to easily access and understand it, a metaphorical tunnel has to be dug beneath the surface from the patient - to the provider - to your insurance company. Surprised it's not already? Like we said, it takes a LOT of work to look this good. X12 takes the MANY data fields required to process a request - be that determining your healthcare eligibility or processing a claim - and connects them in a real time - readable manner.
To paint a clearer picture, a real life application seems fitting. It should be noted that X12 can be used not only for eligibility or claims (as noted above) but also claims status, enrollment, referrals and authorizations.
When Barb from the front office of Dr. Smith's practice is looking to process eligibility requests at 11am on a Tuesday in March, she has a few choices - one without access to X12 and one with.

Without X12:

  • Barb finds patient file>
  • Barb picks up phone>
  • Barb dials insurance company>
  • Barb waits on hold for 13 minutes>
  • Barb finally talks to support operator Glen>
  • Barb gives patient info to Glen>
  • Glen puts Barb on hold again, this time for 8 minutes>
  • Glen comes back and asks for a piece of information he missed the first time>
  • Glen puts Barb on hold once again>
  • Barb waits on hold for 7 minutes>
  • Glen comes back and gives Barb her patient's coverage plan>
  • Glen and Barb exchange pleasantries and hang up


This interaction for one patient took no less than 30 minutes.

With X12:

  • Barb inputs patient information in computer>
  • Barb receives immediate, complete output from patient's insurance company with benefit information including eligibility (if they have current coverage with the provider), deductible information/status, out of pocket maximum and beyond.


This interaction for one patient took no more than 1 minute (including time for Barb to refill her coffee) and produced much more complete and rich information. Wouldn't it be nice if Barb could also tell you how much a particular service will count against your deductible? #transparency #thefuture


Hopefully this gives you a sense not only of what X12 is - but really, what it means for patients, providers, insurers - and of course, the future of health. Stay tuned for more X12 posts to come and remember, #sharethehealth.


The opinions expressed in this blog are of the authors and not of PokitDok's. The posts on this blog are for information only, and are not intended to substitute for a doctor-patient or other healthcare professional-patient relationship nor do they constitute medical or healthcare advice.

  Tags: API, Dev, Providers


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