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NATIONAL HEALTH PLAN IDENTIFIER
The Establishment of a Standard for a National Health Plan
Identifier Issue Paper
For Discussion Purposes
This paper presents information and issues relating to the National
Health Plan Identifier (PAYERID), a candidate for the standard identifier
for health plans. This paper is to be used for discussion purposes
only. It does not necessarily reflect the official Department of
Health and Human Services (DHHS) position on all issues. The official
position will be conveyed in a Notice of Proposed Rulemaking (NPRM), to
be published in the Federal Register, which will recommend the PAYERID
as the standard health plan identifier. The NPRM will solicit public
comment on many of the issues presented in this paper.
We propose that a health plan be defined as an individual plan or group health
plan that provides, or pays the cost of, medical care. We would include
group health plans offered by self-insured employers.
Where a health plan conducts business through agents (third party
administrators, pharmacy benefit management companies, and entities that
are under "administrative services only" [ASO] contracts) the agents must
comply with HIPAA requirements as if they were health plans. Such agents of defined plans
would be issued plan identifiers.
The term "health plan" may have different meanings for different entities.
Many people consider their health care policies to be health plans, while
others think of a health plan as the entity that bears the risk of or administers
policies. We believe that the latter interpretation is the correct
one for purposes of the regulation. Enumerating all health care policies
would not be viable. We would exhaust the supply of numbers very
rapidly as policies may change every year. It would also be very
difficult to keep the data current.
The Congress has included two policies in the definition of a health plan
(Medicare supplemental and long-term care policies). These two types
of policies would be enumerated as health plans as defined in this rule.
That is, the issuer of the policy would be enumerated.
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Health Plans:
- Group health plans
- Health insurance issuer
- Managed care organizations
- Medicare program
- Medicaid programs
- Medigap plans
- Long term care plans
- Employee welfare benefit plans offered by two or more employers
- Active military plans
- Veterans health care program
- Civilian Health and Medical Programs of the Uniformed Services (CHAMPUS)
- Indian health service program
- Federal Employees Health Benefit Plan
- Any other individual or group health plan, or combination thereof, that provides or pays for the cost of medical care
- Self-insured employer group health plans
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There is no one comprehensive scheme to enumerate health plans;
existing enumeration systems are incomplete and overlapping. For
example, State regulators use the National Association of Insurance Commissioners’
Company Code; the Internal Revenue Service and the Department of Labor
use a 12-digit identifier consisting of the 9-digit employer number and
a 3-digit plan designation; health care institutions and other health care
providers use their own codes or alphabetic and numeric listings of names
and addresses; and Medicare fiscal intermediaries and carriers use locally
devised codes. A single health plan can have several of these identifiers,
each assigned by different organizations for a specific purpose.
Some health plans are also assigned multiple identifiers by the same organization
because they are known by more than one name.
The lack of a standard identifier for health plans costs the health
care industry time and money. This is mainly due to the inability
to route transactions in a timely way. For example, a health care
provider may find that its claim has been routed to several locations before
arriving at the correct health plan for payment. This misrouting
of transactions results in delayed payments to the beneficiary or provider.
A unique health plan identifier would simplify and improve the routing
of health care transactions and the administration of health care plan
benefits.
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In April 1994, HCFA initiated the development of a unique numbering
system for health plans (hereafter referred to as the national health
plan identifier or PAYERID) to improve the administration of the Medicare
and Medicaid programs. The purpose of the initiative was to develop
and implement a national model for cost effective identification of health
plans that would facilitate the routing of health care transactions
to the health plan responsible for payment. The Medicaid program
always pays after any other coverage the patient may have. Use of
a single, national numbering system for health plans would assist State
plans in assuring that their health care expenditures are limited to amounts
not reimbursable under other plans.
The unique identifier would also assist the Medicare secondary payer
program. By law, Medicare is not the primary health plan (1) when
certain Medicare beneficiaries are also covered under employer group health
plans, or (2) when the illness or injury is covered under liability or
no-fault insurance or workers’ compensation. Currently, it is difficult
to identify exactly what other coverage a Medicare beneficiary has, and
millions of Medicare dollars are spent for care that is the primary responsibility
of another health plan. Use of a unique identifier for each health
plan would help to reduce inappropriate expenditure of funds and expensive
recovery efforts. A national unique health plan identifier would
also assist Medicare in transferring claims for Medicare beneficiaries
covered by Medigap policies and in transmitting complementary claims to
and from other health plans. The health plan identifier would supply
the correct electronic address when Medicare needs to send a crossover
claim electronically to another health plan.
Pursuant to the passage of the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), and in consultation with the industry, HCFA is proposing
that PAYERID be adopted as the national standard identifier for health
plans.
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The PAYERID is a 9-digit numeric identifier. The ninth digit of
the PAYERID is a check digit, which ensures the accuracy of the number
entered on the transaction. The check digit algorithm is a recognized
International Standards Organization (ISO) standard. The PAYERID
format would allow for the creation of approximately 100 million unique
identifiers.
Users would be assigned access privileges based upon the type of on-line
access (download or browse capability). In addition, users could
also request a printed or electronic directory.
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On August 21, 1996, Congress passed the HIPAA, Public Law 104-191. Title II of HIPAA amended the Social Security Act to add provisions
to address the need for a standard health plan identifier and other standards
that would lead to improved electronic transfer of health information. It mandates the
establishment of these standards for use in the following electronic transactions:
health claims, health encounter information, health claims attachments,
health plan enrollments and disenrollments, health plan eligibility, health
care payment and remittance advice, health plan premium payments, first
report of injury, health claim status, and referral certification and authorization.
The Secretary of the Department of Health and Human Services (HHS) is
charged with adopting the administrative simplification standards.
The standards are applicable to health plans, health care clearinghouses,
and health care providers that transmit any health information in electronic
form in connection with the transactions listed above.
The HIPAA stipulates the way in which the standards are to have been, or
are to be, established, the consultations required, and the dates by which
the standards must be set and implemented. The standards must be
set and
implemented within 24 months of the adoption of the final rule (small health plans have
36 months).
The HIPAA also gives HHS the authority to impose penalties on providers,
health care clearinghouses, and health plans that delay, do not use, or
misuse the standards. The process by which modifications and changes to
standards may be made is also contained in the legislation.
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To comply with HIPAA, HHS must rely on the recommendations of the National
Committee on Vital and Health Statistics (NCVHS), consult with appropriate
State, Federal, and private agencies or organizations, and publish the
recommendations of NCVHS in the Federal Register in establishing the standard
health plan identifier.
HHS has organized interdepartmental implementation teams to identify
and assess potential standards, including those for a health plan identifier.
A separate team addresses cross-cutting issues and coordinates the work
of the implementation teams. The teams consult with NCVHS and standard
setting organizations. The teams are charged with developing regulations
and other necessary documents and making recommendations for the various
standards to the HHS’ Data Council. (The Data Council is the focal
point for consideration of data policy issues. It reports directly
to the Secretary of HHS and advises her on data standards and privacy issues.)
HHS will develop recommendations for the standards to be adopted.
The recommendations will be put in the form of proposed rules and will
be published in the Federal Register. Each proposed rule provides
the public with a 60-day comment period. The public comments will be reviewed
and analyzed, and Final Rules will then be published in the Federal Register;
the Final Rules will announce the adoption of the standards. In addition,
HHS will distribute standards and coordinate preparation and distribution
of implementation guides for each one.
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HCFA has assessed various options for a health plan identifier against
the criteria developed by HHS and those in HIPAA. The PAYERID is
the only identifier for health plans that meets all of the selection criteria.
Therefore, the PAYERID is being proposed to be adopted as a national identifier
for health plans.
The PAYERID has been designed so that all types of health plans, as defined above,
would be enumerated. Its design also includes an expansion
capability, if it becomes necessary in the future. The PAYERID registry,
with the capacity to enumerate approximately 100 million health plans,
provides for an acceptable number of potential identifiers for health plans.
The PAYERID conforms to the ASC X12N workgroup system file specifications
for the health plan identifier. The PAYERID system, as described
herein, is consistent with the intent of the Information Technology Management
Report Act of 1996 and Executive Order 13011 on Federal Information Technology
to promote efficiency and effectiveness through use of electronic commerce
to streamline Government business processes. PAYERID does not
contain embedded systemic intelligence.
The PAYERID would be administered by HCFA, ensuring consistent policies,
updates, and improvements. PAYERID numbers would be assigned through
one registry, thereby ensuring that each health plan would be identified
uniquely and would only receive one number. The PAYERID registry
would be in the public domain and can be widely disseminated to the health
care industry. The PAYERID system would not house any individual
identifiers that would be subject to the Privacy Act. The PAYERID
would improve coordination of benefits and one-stop billing efforts by
precisely identifying health plans and supplying mail and electronic addresses
for the routing of health care transactions.
The PAYERID would simplify the identification of health plans by substituting
a numeric identifier for the health plan’s name currently used today.
This allows for low implementation cost to health plans and other users
of the system. User guides are being developed to assist users in
a smooth transition to the PAYERID. The data collection burden on
health plans would be minimal. The data being collected by the PAYERID
database are already available on the health plans’ files. The PAYERID
system would only be consolidating the data in one location. The
PAYERID is designed to be used in all current computer environments and
is independent of any specific computer platform or protocol transmissions.
In the development of the PAYERID, various organizations have been consulted,
including those that the legislation requires. Subsequently, the
PAYERID has been endorsed by several government and private organizations:
- National Committee on Vital and Health Statistics
- U.S.A. Registration Committee
- The State of Minnesota
- National Uniform Billing Committee
- American Dental Association
- National Uniform Claim Committee
- WEDI supported the general concept of the PAYERID
- National Council for Prescription Drug Programs
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The HIPAA requires that provisions of industry trading partner agreements that stipulate data
content, format definitions, or conditions that conflict with the adopted
standard will be invalid beginning 36 months from the effective date of
the final rule for small health plans, and 24 months from the effective
date of the final rule for all other health plans.
At the WEDI Healthcare Leadership Summit held on August 15, 1997,
it was recommended that health care providers not be required to use any
of the standards during the first year after the adoption of the
standard. However, willing trading partners could implement any or all
of the standards by mutual agreement at any time during the 2-year
implementation phase (3-year implementation phase for small health
plans). In addition, it was recommended that a health plan give its
health care providers at least 6 months notice before requiring them to
use a given standard.
The PAYERID NPRM will be soliciting comments specifically on early
implementation as to the extent to which it would cause problems and how
any problems might be alleviated.
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The national health plan identification (PAYERID) system would be implemented
through a central registry. Its administrator would validate health
plan information, establish on-line accounts, issue PAYERIDs, resolve potential
duplicative situations, provide all necessary maintenance, and provide
outreach to all affected entities. The PAYERID registry would be
a comprehensive system to be used nationally for identifying and uniquely
enumerating all health plans. In addition, the registry would provide
on-line access and distribute registry information.
The PAYERID host computer system would provide operational support of
registry functions and reporting. The PAYERID system design allows
for numerous search criteria. System edits would be added to eliminate
various data entry mistakes. The primary components of the host system
would include the database server, which houses the master PAYERID registry,
and the World Wide Web Server where the PAYERID user interface client applications
would reside. The preferred method of gaining access to the PAYERID
system would be via the Internet.
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Health plan means an individual or group plan that provides, or pays the
cost of, medical care. Health plan includes the following, singly or in
combination:
- Group health plan. A group health plan is an employee welfare
benefit plan (as currently defined in section 3(1) of the Employee
Retirement Income and Security Act of 1974, 29 U.S.C. 1002(1)),
including insured and self-insured plans, to the extent that the plan
provides medical care, including items and services paid for as medical
care, to employees or their dependents directly or through insurance, or
otherwise, and
- Has 50 or more participants; or
- Is administered by an entity other than the employer that
established and maintains the plan.
We would include employers that offer self-insured employee welfare
benefit plans as health plans. The plan, not the employer, would obtain the PAYERID. A self-insured employee welfare benefit plan is defined as when no formal insurance plan is purchased by
a sponsor (such as an employer).
- Health insurance issuer. A health insurance issuer is an insurance
company, insurance service, or insurance organization that is licensed
to engage in the business of insurance in a State and is subject to
State law that regulates insurance.
- Health maintenance organization. A health maintenance organization
is a Federally qualified health maintenance organization, an
organization recognized as a health maintenance organization under State
law, or a similar organization regulated for solvency under State law in
the same manner and to the same extent as such a health maintenance
organization. These organizations are also called managed care organizations. These
organizations may include preferred provider organizations, provider
sponsored organizations, independent practice associations, competitive
medical plans, exclusive provider organizations, and foundations for
medical care.
- Part A or Part B of the Medicare program under title XVIII of the
Social Security Act.
- The Medicaid program under title XIX of the Social Security Act.
- A Medicare supplemental policy (as defined in section 1882(g)(1) of
the Social Security Act). Section 1882(g)(1) of the Act defines a "Medicare
supplemental policy" as a health insurance policy that a private entity offers a
Medicare beneficiary to provide payment for expenses incurred for
services and items that are not reimbursed by Medicare because of
deductible, coinsurance, or other limitations under Medicare. The
statutory definition of a Medicare supplemental policy excludes a number
of plans that are generally considered to be Medicare supplemental
plans, such as plans for employees and former employees and for members
and former members of trade associations and unions.
- A long-term care policy, including a nursing home fixed-indemnity
policy. A long-term care policy is considered to be a health plan
regardless of how comprehensive it is.
- An employee welfare benefit plan or any other arrangement that is
established or maintained for the purpose of offering or providing
health benefits to the employees of two or more employers. These are
referred to as multiple employer welfare arrangements (MEWAs), Taft-Hartley trust plans, employer association group health plans, and multiple employer trust plans (METs).
- The health care program for active military personnel under title 10
of the United States Code.
- The veterans health care program under 38 U.S.C., chapter 17. This
plan primarily furnishes medical care through
hospitals and clinics administered by the Department of Veterans Affairs
for veterans with a service-connected disability that is compensable.
Veterans with non-service-connected disabilities (and no other health
benefit plan) may receive health care under this plan to the extent
resources and facilities are available.
- The Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS), as defined in 10 U.S.C. 1072(4). CHAMPUS primarily covers
services furnished by civilian medial providers to dependents of active
duty members of the uniformed services and retirees and their dependents
under age 65.
- The Indian Health Service program under the Indian Health Care
Improvement Act (25 U.S.C. 1601 et seq.). This program furnishes
services, generally through its own health care providers, primarily to
persons who are eligible to receive services because they are of
American Indian or Alaskan Native descent.
- The Federal Employees Health Benefits Program under
5 U.S.C. chapter 89. Depending on the plan, the services may be
furnished on a fee-for-service basis or through a health maintenance
organization.
- Any other individual or group health plan, or combination thereof,
that provides or pays for the cost of medical care.
Small health plan means a group health plan, including self-insured
employee welfare benefit plans, with fewer than 50 participants that is
not administered by the employer that established and maintains the
plan.
(Note: Although section 1171(5)(M) of the Act refers to the "Federal
Employees Health Benefit Plan," this and all future rules adopting administrative
simplification standards will use the correct name, the Federal Employees
Health Benefits Program. One health plan does not cover all Federal
employees; there are over 350 health plans that provide health benefits
coverage to Federal employees, retirees, and their eligible family members.
Therefore, we will use the correct name, the Federal Employees Health Benefit
Program, to make clear that the administrative simplification standards
apply to all health plans that participate in the program.)
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We propose assessing fees for data services such as copies of print and
CD-ROM versions of the directory and on-line queries for registry users and general inquiry user accounts.
In addition, entities such as value added networks, billing services, and
other EDI vendors that purchase the PAYERID database with the intent to
market its resale, in either whole or as part of a related product, would
be charged a fee.
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PAYERIDs will be randomly generated and assigned at the health plan level. Any health plan that meets the definition of a health
plan under HIPAA and the regulation would be assigned a PAYERID.
If a health plan had "subordinate" health plans under its business
structure, it would be known as the parent health plan or "umbrella"
health plan. The "umbrella" health plan's PAYERID would be considered
the default and all health plans under the "umbrella" health plan would
each receive a PAYERID and be linked in the registry.
If an "umbrella" health plan offers substantially different plans
each different plan would receive a PAYERID. We would not consider
plans to be different if they are simply variations to the basic plan,
such as riders, options, deductibles, benefit inclusions, certification
requirements, provider networks. We would consider the following to be
different kinds of group health plans: Fee-for-Service, Point-of-Service, Preferred
Provider Organizations, and Health Maintenance Organizations. For
clarity we offer the following examples:
- ABC Insurance Company offers a fee-for-service, a health
maintenance organization, and a preferred provider organization health
plan. Each of these plans would be assigned a separate PAYERID.
- ABC Insurance Company offers HMO health plans to several
employers. The health plans are the same except for several options.
The insurance company would receive one PAYERID to cover all of the HMO
health plans.
- ABC Insurance Company offers a point-of-service plan to
several employers. One plan covers hospital and physician services, the
other plan covers physician services. Each plan would receive a
separate PAYERID.
- If an insurance company offers the same basic HMO health plans
to employers in several states, that insurance company (health plan)
would receive one PAYERID. Regardless of where the health plan is sold
or to whom, the health plan would be identified on electronic health
care transactions by the same PAYERID.
- If an employer sets up an employee benefit plan, pays for it
through company funds, and manages this benefit plan, the employer's
plan, not the employer, would receive the PAYERID.
- If an employer sets up an employee benefit plan, pays for it
through company funds, and a third party administrator (TPA) manages the
plan, the employer's plan, not the employer or the TPA, would receive
the PAYERID. Although the TPA would receive its own PAYERID, that
PAYERID would not be used to identify the employer's health plan.
- Medicare and Medicaid State programs are health plans which
would receive PAYERIDs. These health plans contract with carriers and
intermediaries and fiscal agents to process their health care
transactions. These entities function as third party administrators
and, as such, each would receive a PAYERID. The entity would be linked
back to the "umbrella" health plan (Medicare or Medicaid state program, respectively).
- Federal Employee Health Benefits (FEHB) plans are offered to
active and retired Federal employees and their dependents. If the same
plan offered to Federal employees is offered to private customers, with
no substantially different variations to the basic plan as discussed
earlier, the FEHB plan would receive the same PAYERID as the private
health plan.
- ABC insurance company and XYZ insurance company offer totally
different health plans. XYZ insurance company is bought-out by ABC
insurance company. Each of XYZ health plans and ABC health plans would
maintain their current PAYERID. Only the PAYERID assigned to the parent
health plan would be retired. However, if ABC insurance company merges
with XYZ insurance to form DEF insurance company, the PAYERIDs of ABC
and XYZ would be retired. DEF insurance company would be assigned a
PAYERID.
Health plans would not receive a PAYERID to route health care
transactions to separate business divisions within the same health plan.
Routing past the single address would be the responsibility of the
health plan. If a health plan incorporates special benefits (such as
vision, dental, long term care, and pharmaceutical services) through
other health plans, the health plan's identifier for each of these
benefits could be indicated in the health plan's records.
PAYERIDs will not replace any numbers currently used to identify processing
locations (such as the group number, policy and product levels, enrollment
codes, etc.).
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We propose to enumerate all health plans, as defined in this
regulation, in phases. We would obtain lists from Medicare, Medicaid,
health insurance associations, and third party associations to develop
an initial mailing file of potential health plans. The first phase
would enumerate all health plans on this initial file. The entities
included in the first phase of the enumeration process would be as
follows:
- Medicare program. Each Medicare contractor and health
maintenance organization would receive a health plan identifier.
- Medicaid program. Each Medicaid State agency and fiscal agents
would receive a health plan identifier.
- Health Insurance Issuers. Each health insurance issuer would
receive a health plan identifier.
- Third Party Administrators. Each third party administrator,
as defined by regulation, would receive a health plan identifier.
Health plans enumerated in the first phase would be sent a
registration package, via on line, surface mail, or fax (the means would
depend upon the type of information we already have on file).
The second phase would include all other health plans, such as
other Federal agencies and employers that offer self-insured employer
group welfare benefit plans, that were not contacted through the first
phase. Through health plan associations and the general insurance
industry, we would publicize the availability of registration material
to alert health plans not included in the first phase to come forward
and apply for a health plan identifier.
Health plans enumerated in the second phase would request a
registration package through the registry. The registry would request
specific business information that would include such items as the
requestor's business name and address and telephone and fax numbers.
Health plans enumerated in either phase would be sent a
registration package via on-line, surface mail, or fax, as appropriate.
The registration package would contain a copy of the application form
(HCFA-856), which would be completed on-line, and its instructions; the
agreement between the registry administrator and the health plan; the
procedures to follow for submitting the signed agreement to the registry
administrator; an account number; and a temporary password.
The health plan would now have the authority to access the PAYERID
registry to apply for its health plan identifier. The health plan would
complete the application on-line and the registry administrator would
validate the information contained within to ensure that the applicant
is a health plan.
The registry administrator's agreement with the health plan would:
- explain that the health plan would be verified for PAYERID
eligibility;
- describe the authorized and required uses of the PAYERID number;
- describe associated restrictions on the health plan's use of the
registry data;
- describe means for creating and updating records;
- define responsibilities, obligations, and liabilities of each
party; and
- provide termination conditions.
Once the first and second enumeration phases are complete, as an
alternative to the costly process of mailing information and
applications to new health plans, we would like to explore the potential
for requiring a totally electronic process. New health plans would be
required to gain access electronically to information about the process
and the application form as well as submit their completed applications
on-line. The electronic signature standard (published earlier as part
of the security proposed rule) could be used where signatures on paper
would normally be required.
As an option to having health plans contact the PAYERID
administrator individually, we are also offering the concept of an
"authorized plan representative". The "authorized plan representative"
would apply for a PAYERID and establish an account for each of the
health plans' it represents. An "authorized plan representative" must
itself be a health plan that insures or provides administrative services
for health plans that are its customers. For purposes of this
regulation, third party administrators, "administrative service only"
contractors, and pharmacy benefit management companies would be included
as "authorized plan representatives". The "authorized plan
representative", under the terms of its contract with the registry's
administrator, would be required to certify to the registry that it
holds a signed authorization from each health plan it represents.
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The PAYERID would collect and store in the PAYERID Registry a variety
of information required to identify a health plan uniquely. The data
elements are:
Data Elements
|
Comments
|
| Primary name of Applicant |
Primary name by which the applicant is to be addressed. |
| Account number |
On-line access control identifier, assigned by system registrar. |
| Effective Date |
Date on which PAYERID is effective. |
| Termination date |
Date on which PAYERID terminates. |
| PAYERID number |
Required for updates. |
| Applicant or Affiliate indicator |
Indicates whether applicant is affiliated with another plan. |
| Previous PAYERID |
Terminated PAYERID for applicant. |
| Description or Purpose of PAYERID |
Describe purpose or usage of PAYERID (e.g., XYZ Indemnity Plan) |
| Affiliate PAYERID |
PAYERID of affiliate |
| Contact position |
Department or title to which correspondence should be addressed. |
| Primary mailing Address |
|
| Contact telephone number |
|
| FAX number |
|
| E-mail address |
|
| EDI address |
A multiple-entry field listing each valid transaction and service. |
| Express delivery address |
|
| Submit transaction to PAYERID |
If applicant is not the processor of the transactions. |
| Other PAYERIDs |
If different entities process pharmacy, dental, vision or long term
care transactions. |
| Alias name |
d/b/a |
| Other identifiers |
National Provider Identifier, NAIC CoCode, Medicate Contractor Number,
Medicaid Plan Number, Medicare HMO Contract or Plan Number. |
| Tax ID number |
Can only be viewed by applicant. |
| Applicant type |
See list below. |
| Group Health Plan Risk Type |
HMO, PPO, FFS or POS |
Specifications for the data fields may be found in the document entitled Proposed PAYERID
Data Elements.
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- Group health plan (TPA, ASO, PBMC, employer, union)
- Health insurance issuer
- Health maintenance organization
- Medicare program
- Medicaid program
- Multiple employer plan
- Department of Defense
- Department of Veterans Affairs
- CHAMPUS
- Indian Health Service
- Federal Employees health benefit program
- Other individual or group health plans
We are providing the following definitions for the four plan types listed
above:
Health Maintenance Organization (HMO): An HMO is a legal entity
which provides or arranges for the provision of basic and supplemental
health services to its members and is organized and operated in the manner
prescribed by, and otherwise meets the requirements of, §1301 of the
Public Health Service Act and 42 CFR 417.100 - 417.109. These may
include organizations such as individual practice associations (IPAs) and
provider sponsored organizations (PSOs).
Preferred Provider Organization (PPO): A program in which contracts
are established with providers of medical care. Providers under such
contracts are referred to as preferred providers. Usually, the benefit
(fewer copayments) for services received from preferred providers, thus
encouraging members to use these providers. Members are generally
allowed benefits for non-participating provider’s services usually on an
indemnity basis with significant copayments or self-funded. Under
a PPO arrangement, providers may be, but are not necessarily, paid on a
discounted fee-for-service basis.
Fee-for-Service (FFS): A method of payment whereby a health care provider is reimbursed on the basis of the charge for each service or item provided to the patient. This category includes plans that pay professional and ancillary providers on the basis of amounts or formulas based on individual encounters, items of service or supply, indemnity plans, or tables of allowable reimbursement.
Point-of-Service Plan (POS): A type of health plan allowing the covered
person to choose to receive a service from participating or a non-participating
provider, with different benefit levels associated with the use of participating
providers. Point-of-service can be provided in several ways.
- An HMO may allow members to obtain limited services from non-participating
providers;
- An HMO may provide non-participating benefits through a supplemental
major medical policy;
- A PPO may be used to provide both participating and non-participating
levels of
coverage and access;
- Various combinations of the above may be used.
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Data would be disseminated using two access methods: directory and
on-line. Users would be assigned access privileges based on the
dissemination method they require to obtain unique identifier
information for use in conducting health care transactions. A different
fee would be associated with each of these access methods. The two
methods of data dissemination are explained below.
1. Directory
The paper or electronic copy (CD-ROM or diskettes) of the
registry, which is updated quarterly, could be requested. Although the
directory is available to health care providers, health plans, health
care clearinghouses, and any entity that desires a copy, we envision
mostly health care providers using this method. We anticipate that
there would be other means for health care providers to obtain the
PAYERID data they need to process health care transactions. For
example, a health plan would likely make its PAYERID available in a
letter or notice to its preferred health care providers and to health
plan members, who would in turn pass that information onto the health
care provider. This process may replace the need of some health care
providers having to purchase a directory or subscribe to the registry,
either directly or indirectly. Over time, we envision that the PAYERID
would be placed on health insurance cards of health plan members.
The cost to purchase a paper directory would include mailing and
handling costs and would factor in the cost of the voluminous amount of
data the directory would contain. Electronic directories would be made
available in an Adobe Acrobat portable document format or ASCII, tab
delimited format.
2. On-line Access
The other method of disseminating data would be on-line access to
the registry. In addition, there are two types of on-line access:
download capability and search capability.
These two types of on-line access are available to specific users
as explained below.
- Health plan: A health plan has on-line access only to its
own record. There are no fees associated with obtaining a PAYERID or
maintain the information on its own record.
- Registry users: A registry user would establish an account
with the registry administrator for on-line access. Registry users
would be able to download the entire PAYERID registry onto its own
computer. The registry user could not make any changes to any of the
information contain in the PAYERID registry. The entity would receive
bi-monthly data changes electronically over a telecommunication
connection, apply the changes to its copy of the data file, and
authenticate the accuracy of the entire resultant data file. There are
fees associated with download privileges. Registry users could be a
third party administrator, health plan, health care provider, health
care clearinghouse, or any other type entity that downloads and
maintains a complete copy of the PAYERID registry on its own computer.
If a health plan wants download privileges it would apply to
become a registry user. It would not have to establish another account
but would used its existing health plan account.
Registry users could enter into contracts with other entities to
perform specific services supporting those entities' health care
transactions. For example, if a health care clearinghouse or billing
service applies to become a registry user, health care providers or
health plans could contract with them to process their health care
transactions.
- General inquiry user: A general inquiry user would establish
an account with the PAYERID registry administrator for on-line search
privileges. A general inquiry user could be a health care provider, a
health plan, or any other type entity that performs on-line searches of
the PAYERID registry. General inquiry users would have browsing
privileges only and could not make any changes to the information
contained in the PAYERID registry.
Registry users would also have to sign an agreement with the
registry administrator prior to establishing an account. The agreement
would:
- Describe the authorized and required uses of the PAYERID number.
- Describe associated restrictions on the use of the registry
data.
- Define responsibilities, obligations, and liabilities of each
party.
- Specify pricing and payment terms for downloading privileges and
use of the PAYERID registry.
- Provide termination conditions.
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Two years after adoption of this standard (3 years for small health
plans) the PAYERID must be used generally in the health care system and
specifically in connection with the health-related financial and administrative
transactions identified in section 1173(a). The PAYERID may also be used for any other lawful activity requiring individual identification of health plans. It may not be used in any activity
otherwise prohibited by law.
Examples of approved uses would include:
- Health plans would be required to use their own PAYERID to
identify themselves in electronic health care transactions or related correspondence.
- Health plans would be required to use other health plans’
PAYERIDs as necessary to complete electronic health care transactions and
on related correspondence.
- Health plans could communicate PAYERIDs to other health plans
for coordination of benefits.
- Health plans could use PAYERIDs in their internal files to
process transactions.
- Health care providers would be required to use PAYERIDs on
electronic transactions and in communication with other health care
providers or health plans, as required in the applicable implementation
guide for identification of entities within the transaction where such
entities are functioning in the role of health plans.
- Health care clearinghouses could use PAYERIDs in their internal
files.
- Health care clearinghouses would be required to use PAYERIDs
to create and process standard electronic transactions and in electronic
communications with health care providers, health plans, and other health
care clearinghouses.
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We summarize here how the implementation of the PAYERID would affect
health care providers, health plans, and health care clearinghouses.
1) Health Care Providers
Health care providers that conduct electronic transactions as identified
in section 1173(a) with other health care participants (such as other health
care providers, health plans, and employers) would be required to use the
PAYERID of the patient’s health plan in those transactions.
Health care providers would have to include the PAYERID for the primary
health plan on standard transactions, and they would also have to obtain
and use the PAYERID on standard transactions involving other health plans
(for example, for identifying secondary, tertiary or third party liability
payers). This would apply to all health care providers that choose
to deal in electronic commerce, despite their practice size or setting.
Currently, health care providers must include the name and address of these
health plans in alphabetic or numeric form. After implementation,
health care providers would no longer have to keep track of and use different
identifiers for different health plans. Also, since the PAYERID would
replace the need to type the name and address on electronic transactions,
it should reduce the time it takes to complete forms and transactions.
Health care providers that are indirectly involved in electronic transactions
(for example, by submitting a paper claim that a health plan converts to
an electronic crossover claim) would also be able to use PAYERIDs.
Health care providers that do not contract with an entity to process their
health care transactions may want on-line access to the PAYERID system
to identify the correct PAYERID. These health care providers would
have to apply for an account via the registry. In addition, health
care providers could request, via the registry, a paper or electronic copy
of the PAYERID directory.
2) Health Plans
All health plans, regardless of whether they comply with the provisions
of our regulations through a health care clearinghouse or directly, would
have to apply for a PAYERID via the PAYERID registry. Each health
plan would have to begin to use its PAYERID for all transactions listed
in section 1173(a) within the time period specified by the law. Health
plans would be able to make changes to the data contained on their own record in the PAYERID
system. The changes would be made available to other health
care participants on a bi-monthly basis.
Health plans would be able to access and maintain their own data on
file in the PAYERID system. There would be no charge for this service.
However, health plans that want download privileges would have to become a registry user. In addition, health plans could request, via the registry, a paper or electronic copy of the directory.
3) Health Care Clearinghouses
Health care clearinghouses would be required to use a health plan’s
PAYERID on electronic standard transactions requiring a PAYERID.
Health care clearinghouses may want on-line access to the PAYERID system.
These health care clearinghouses would have to apply for an account via
the registry. In addition, health care clearinghouses could request,
via the registry, a paper or electronic copy of the directory.
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Please send any questions or comments on "PAYERID" to
:
hlthplan@hcfa.gov
PAYERID Brief Background
PAYERID Proposed PAYERID Data elements
PAYERID Frequently Asked Questions
Return to HCFA Initiatives
Last Updated March 11, 1998 |
