2 On or before November 7, 2016 If you identify a health plan in a - - PDF document

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Laurie Darst Mayo Clinic Revenue Cycle Regulatory Advisor & WEDI HPID Workgroup Co-Chair

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• Health Plan: an individual or group plan that

provides or pays the cost of medical care

• Individual or group plans
• Health insurance issuers
• HMOs
• Employee welfare benefit plans
• Government Programs
• Group health plans*
• Including self funded group health plans

All controlling health plans (CHP) must obtain

an HPID

• November 5, 2014 (all except small plans)
• November 5, 2015 (small plans)

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 Controlling health plan (CHP) A health plan that

controls

• Its own business
• Its own actions
• Its on policies, or
• Is controlled by an entity that is not a health plan
• Required to obtain an HPID

 Subhealth Plan (SHP) A health plan whose

business activities, actions or policies are directed by a CHP

• Eligible, not required to obtain an HPID
• Health Plan and Other Entity Enumeration

Systems (HPOES)

• Housed within CMS’ Health Insurance Oversight System
• https://portal.cms.gov/
• Work with your Legal Area
• Consider internal business needs
• Consider external impacts
• Consider potential impact of the impending

certification rule

• Make sure to enumerate before November 2014

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• On or before November 7, 2016
• If you identify a health plan in a covered

transaction, you must begin using the HPID as the identifier

• If you do not identify a health plan in a covered

transaction, then you do not have to begin using the HPID

 HPID may be used for any other lawful purpose

• We have a definition from CMS on Health Plan
• However, the health care industry tends to

use the terms ‘health plan’ and ‘payer’ synonymously

• CMS does not use the term ‘payer’ and has no definition for

this term

• The majority of the instructions in the TR3s use the term

‘payer’

• The industry currently routes all transactions using a “payer

id”.

• Moving from a ‘payer id’ routing process to a HPID (and

payer id) routing process could cause significant work and risk for the industry

• Health plans who plan to use HPIDs in the

transactions will need to contact all their providers and clearinghouses/vendors to communicate their new enumeration schema

• CMS has indicated the HPOES database will not be

made available to the industry, at least initially

• Based on enumeration schemas, there may be

many more HPIDs enumerated compared to one Payer ID

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• Providers will need to update their practice

management systems with HPID mapping to their insurance masters

• Clearinghouses will need to convert payer ids

to HPIDs

• Routing, editing, reports, and billing
• Misrouted claims/transaction could cause a

significant privacy risk

• Significant multi-stakeholder resources will

be required in order to use the HPID in transactions

• No perceived benefit to the industry– only

cost

• WEDI’s main recommendation to CMS:

require enumeration, but do not require use in the transactions

• What does the term ‘payer’ mean to the

industry and how does that impact the use of payer id and HPID in the transactions?

• WEDI and X12 are working together to define

the term ‘payer’

CMS Comments:

• If you identify a health plan in a covered transaction, you must begin using

the HPID as the identifier

• If you do not identify a health plan in a covered transaction, then you do not

have to begin using the HPID

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• Health Plans should enumerate their CHPs and

SHPs prior to November 2014 (or November 2015 if

small health plan)

• Watch for further information on the definition of

‘payer’ and how that may impact usage in the transactions

• If a health plan decides they are going to identify

themselves as a health plan in the transactions, determine how you plan to communicate your HPID to all other stakeholders

• Other stakeholders should determine how they will

handle HPID information

 CMS HPID Website

http://www.cms.gov/Regulations-and- Guidance/HIPAA-Administrative- Simplification/Affordable-Care-Act/Health- Plan-Identifier.html

• HPOES User Manual, HPID application process

 CMS eHealth Website

http://www.cms.gov/eHealth/

• eHealth University, blogs, other resources

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