PayorID.com—The Solution for the HIPAA National Health Plan Identifier

PayorID.com now has available via the Internet, registry information on all health plans in the nation.  Managed Healthcare Information Services (MHIS), has established a health plan registry and reference for its hospital and medical provider clients, and has compiled this database over the past ten years.  MHIS has coped with the issues that HIPAA regulations will address for electronic transactions in the future.  During the development of the registry, MHIS recognized that there are, and will continue to be, unique provider operational issues for structuring insurance master files and electronic commerce.  These experiences have caused MHIS to position itself as a national expert for implementing and transitioning to the National Health Plan Identifier. 

MHIS has developed an efficient system for all providers to maintain their internal insurance master files.  PayorID.com is a source all providers can use to maintain health plan information and to transition their system(s) to a National Health Plan Identifier.  The information required in an insurance master file goes beyond a National Health Plan Identifier code.  Additional data elements are needed that deal with the issuance of financial classes, payor affiliations with managed care contract organizations, interfacing new codes with legacy systems, updating internal files, interfacing multiple internal systems with outside electronic clearinghouses for authorization and claims transactions.

PayorID.com has established for its clients a plancode system and financial classification for every health plan in the nation as well as some international health plans. Every provider that we work with has implemented its own codes, in alphabetic, numeric, or alphanumeric form, for its payors.  These codes may range from three digits to ten digits in length.  The providers have also prepared listings of names, addresses, and mnemonics, which are linked to their internal codes.  In addition to payor plancodes and identifiers, most facilities and large medical groups have established their own financial classification schemes.  The financial classification schemes are unique to each provider.  MHIS updates the information on payors from the data compiled in its national payor data warehouse.  As the national health plan identifiers are issued, MHIS will pass that information across to its clients.

Electronic clearinghouses have also established unique identifier codes for payor identification. These codes are issued for all payors that participate in the claims or eligibility clearinghouse.  The electronic clearinghouse codes help route the claims to payor organizations.  Providers must enter the code on the patient record as part of the data elements that are sent to the clearinghouse for eligibility, authorization, and claims submission.  The largest clearinghouses may cover fifty percent of the covered lives in the United States.  MHIS has included these codes into its databases and interfaces for its clients.  MHIS provides a service to maintain the client’s insurance master file, as well as provide the electronic billing codes issued by various clearinghouses.

States may issue special codes to select Managed Care Organizations, and these codes have been locally established and are not a comprehensive set of codes for all payors.  An example is the OSHPOD codes set up in California for several HMOs and Medical Groups.  MHIS has included these codes in its data warehouse.

Having six thousand hospitals, several hundred medical groups, and hundreds of claims management organizations, a health plan can have several hundred identifiers that has been assigned by different organizations for a specific purpose.  Providers setting up, tracking down, and maintaining information on payors, is clearly less efficient than obtaining this information from a common clearinghouse. 

MHIS is the first to establish that common clearinghouse.  Providers now have an easy transition to the national health plan identifier, by linking their files to the PayorId.com database.  Moreover they can save time and money in the maintenance costs of their payor databases and improve cash flow by having current information on payors, relationships of payors , and relationships with contracting networks.

The healthcare industry loses billions of dollars annually because providers do not use a standard registry and because a standard health plan identifier has not yet been established.  

These unnecessary loses are due to:

MHIS PayorID.com can reduce those costs:

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MHIS PayorID.com—The Source for the Health Plan Identifier

HHS and HIPAA have assessed various options and criteria for a national health plan identifier.  They have not yet finalized the HIPAA standards for the national identifier. Independently, MHIS has developed its PayorID system to meet all the current criteria of our clients and allow for any future needs and criteria of potential clients.   MHIS has positioned PayorID.com to serve as the source for the national identifier for health plans. 

MHIS has reviewed HIPAA position papers and discussions and believes that implementations of any rules on the national health plan identifier can be easily accommodated within MHIS’s information system.

MHIS has created its classification system and PayorID code so that all types of health plans can have unique identifiers.   Managed care is an evolving structure and MHIS has designed the PayorID system to enable new health plan types to be added if managed care implements new types of health plans.   The PayorID.com registry has also been designed with the capacity to issue approximately 100 million health plan identifiers.  The PayorID data conforms and will continue to conform to the ASC X12N workgroup system file specifications for the health plan identifier. 

The PayorID system is also consistent with the intent of the Information Technology Management Report Act of 1996 and Executive Order 13011 on Federal Information Technology.  These Acts promote efficiency and effectiveness through use of electronic commerce to streamline Government business processes. 

PayorID.com currently issues plan identification numbers for 26,000 health plans.  Those numbers and identifiers were designed to meet the needs of MHIS clients.  Our numbering concepts can easily be refined to serve as the source for the National Payor Identifier or to incorporate the National Health Plan Identifier issued for HIPAA.  Our logic and rules are consistent with the preliminary rules suggested for HIPAA.  

The MHIS rules differ because some of our rules cater to the business needs of our clients.  All of our clients use different rules for issuing internal plan identifiers.  MHIS has set up its database and system to accommodate the individual needs of clients. MHIS believes that the providers will need systems that allow them to comply with the use of a common identifier, as defined in the current HIPAA National Plan Identifier paper. Providers will also need to differentiate the contracted health plans with that identifier, from the non-contracted health plans with that identifier. 

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PayorID.com Covers All Payors.

Over the past ten years Managed Healthcare Information Services has consolidated information on over 26,000 payors, 1,000 managed care organizations including Medicare, Medicaid, and other payors and health plan types.  To serve its current hospital clients, MHIS has become a central registry to establish and maintain the national health plan identification PayorID system. 

MHIS Information Specialists call around the country daily, to compile the most accurate and current information on payors, payor affiliates, third-party administrators, managed care networks, employers, and claims offices.  The data is verified and updated regularly to account for changes in addresses, telephone numbers, multiple names, name changes and mergers—which are frequent occurrences in the managed care industry.  Additional PayorID codes are issued for unique health plans that become identified to MHIS but are not listed in the database. The MHIS PayorID.com service allows healthcare providers and billing organizations instant access to the most current data available on all payors.  MHIS maintains the only all payor data warehouse in the nation.

The PayorID registry is a comprehensive national system for identifying and uniquely enumerating all health plans.  PayorID.com provides on-line access via the Internet to distribute registry information.

Interfaces can also be used to integrate the PayorID.com tables with the claims registrations system utilized by the provider.  MHIS has considerable experience in interfacing its insurance master files with the insurance master files of providers.

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MHIS PayorID.com Health Plans, Payor IDs, and Classification System Compared to HIPAA

MHIS issues a new PayorID to every health plan.  The next available alpha/numeric code is issued as each health plan is entered into the PayorID.com data warehouse.  Each and ever health plan that meets the definition of a health plan (see definitions and examples of health plans below) is assigned a PayorID.  MHIS also issues every health plan an affiliation code that enables our clients to identify if a health plan is part of another managed care contracting organization. 

These affiliation codes are not part of the National Health Plan Identifier requirements, but are a critical business need of the health care providers that contract with managed care organizations.  The position papers and the national health plan identifier have focused on the need and logic for codes for efficient electronic transactions.  The HIPAA papers have not focused adequately with other business needs, such as the need for providers to differentiate between contracted health plans, and non-contracted managed care organizations.   The contract status of a provider does not need to be incorporated into the HIPAA National Health Plan Identifier, however providers need ways to efficiently handle this issue.  The MHIS registry currently handles both of these issues. 

The process of compiling a health plan registry and issuing health plan identifiers, started with defining the types of organizations that will be included in the data warehouse.  The following table summarizes the health plan categories used by MHIS.

All the categories used by MHIS fit the definitions of a health plan enumerated in the HIPAA paper.  Rules had to be made regarding when a health plan would be issued a single identifier, or if the health plan should be issued multiple identifiers, because it was considered multiple plans. 

The following examples summarize what happens when MHIS issues a new PayorID to a Health Plan:

1.        A “Parent” Insurance Company offers a Fee-for-Service, a Health Maintenance Organization, and a Preferred Provider Organization health plan, and also contracts with a non-affiliated PPO for selected benefit plans. Each of these plans would be assigned a separate PayorID by MHIS, but the “Parent” health plan identifier is linked to this PayorID.

2.        An HMO health plan has coverage for several employer groups and self enrolled individuals. The health plans are the same except for several benefit options. The HMO is issued one PayorID to cover all of its HMO health plans.

3.        When an HMO health plan has contracted with Medicare or a state’s Medicaid program, the HMO is issued one PayorID for any Medicare risk contract and an additional PayorID for the Medicaid Risk program.  These PayorIDs are then linked to the “Parent” PayorID in the MHIS PayorID.com Data Warehouse.

4.        When an insurance company or an HMO offers a Point-of-Service plan to several employers, one plan covers hospital and physician services, the other plan covers physician services. These plans might use different insurance companies or in the case of the HMO, the Medical Group is capitated for the medical services, and the HMO or a Hospital Physician Organization is responsible for the hospital coverage.  Each plan (Insurer, Medical Group, etc.) is issued a separate PayorID.  These PayorIDs are linked, however, to the “Parent” PayorID in the MHIS PayorID.com Data Warehouse.

5.        When a “Parent” HMO offers the same HMO health plans to employers in several states, that “Parent” HMO or insurance company (health plan) is issued one PayorID for each state. These PayorIDs are linked, however, to the “Parent” PayorID in the MHIS PayorID.com Data Warehouse.

6.        When an employer sets up an employee benefit plan, pays for it through company funds, and manages this benefit plan or uses an agent as a third party administrator (TPA), to manage the plan, the employer's plan is issued the PayorID.

7.        A Third Party Administrator (TPA) is issued its own PayorID, whenever the TPA is identified as the payor on an ID card, rather than an employer name.

8.        Medicare and Medicaid State programs are types of health plans, and are issued PayorIDs. These health plans contract with carriers, intermediaries, and fiscal agents to process their health care transactions. These entities function as third party administrators and, as such, each is issued a PayorID. The entity would be linked back to the “Parent” health plan (Medicare or Medicaid state program, respectively).

9.        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 variations to the basic plan, the FEHB plan is issued the same PayorID as the private health plan.  If the health plan only covers Federal employees enrolled in the plan, then it is issued a PayorID.   When a FEHB health plan contracts with several independent PPOs, a unique PayorID for each PPO is issued. However, these PayorIDs are linked to the “Parent” PayorID in the MHIS PayorID.com Data Warehouse.

10.     When two independent insurance companies merge or an independent insurance company buys another health plan, MHIS uses the following rules: The current PayorID will be maintained for both health plans.  If one of the health plans discontinues use of its name, then that health plan’s name and PayorID is deactivated.   If both companies discontinue using their respective old names, a new entity and PayorID is issued. The names and PayorIDs of the old entities are then deactivated. However, when a client searches PayorID.com using the old name, the new name and PayorID is provided.

11.     Health plans are issued a PayorID to route health care transactions to separate addresses and business divisions within the same health plan.  This has been a requirement of our current clients and the policy of several payors.  MHIS also links these PayorIDs to the “Parent” PayorID in the MHIS PayorID.com Data Warehouse.  If the final HIPAA regulations require the combination into a single PayorID for the separate business addresses and divisions, then MHIS can modify its rules.  However, the unique business requirements of providers may require that separate internal identifiers be maintained, to appropriately allocate revenue among contracted and non-contracted divisions of the “Parent” health plan. 

MHIS has established rules and procedures over the last decade of its business operations, to structure its PayorID database and interfaces to meet the needs of its provider clients.  These rules may differ from the final regulations issued for HIPAA, however, the MHIS database structure is flexible enough for modifications to the rules to meet the HIPPA criteria.

Moreover, the MHIS PayorID database structure is flexible enough to accommodate the unique business requirements of our clients and clearinghouses that access this data.  The ability to integrate PayorID.com data with unique business rules, mission critical information, and links that we carry, is an added value that MHIS brings to the healthcare industry.  MHIS will handle both the requirements that HIPAA and Administrative Simplification have for electronic transactions, and the business requirements that providers have for their internal operations.

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MHIS PayorID.com is a Health Plan Information Portal for Providers

The information in PayorID.com is available via directory and on-line.  MHIS charges various fees for the access to its databases.  Fees are charged for printed directories of health plans classifications, addresses, phones and PayorID code(s).  On-line licenses are sold for single user to multi-users at a single provider site for access and searches of the PayorID.com generic database information.  Clients may also contract with MHIS to interface their existing claims registration system with the MHIS PayorID.com Data Warehouse.

1. MHIS Managed-Care Directory:

The MHIS Managed-Care directory is published quarterly.  The national health plan identifier will be added into the MHIS publication once the codes have been issued under the HIPAA regulations. 

2. PayorID.com—Access and Search:

MHIS has established PayorID.com and is currently enrolling providers to access the health plan data via the Internet.  MHIS has also created classification rules and procedures for every health plan type.  MHIS maintains this system that will easily map the HIPAA National Health Plan Identifiers into PayorID.com databases. This data will be accessible nationwide via the Web.

3. PayorID.com—Electronic Interface: 

MHIS maps plans in a providers claims registration system to the plans in the PayorID.com database.  Out-of-Area Health Plans are generally not maintained in the provider’s system, but can be accessed through the use of custom screens for the provider on PayorID.com.  Providers may view and download data such as, claims address, electronic billing codes, contract phone numbers and web site address from the PayorID.com databases into their system.

The providers’ custom screens and database tables will meet the unique business needs of the provider.  The MHIS PayorID.com interfaces enable the providers to handle the business issues that differ from the national health plan policies.  The PayorID.com interface also allows the provider to transition its existing health plan codes and procedures, into the requirements of the national health plan identifiers.

PayorID.com is independent of any specific computer platform or protocol transmissions, and can be interfaced with many different current computer environments.

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The Effect of the Implementation of the National Health Plan Identifiers on MHIS PayorID.com and its Clients

The implementation of the PayorID on MHIS client health care providers, and information partners:

1. MHIS:

MHIS will add the National Health Plan Identifier into its database, Managed-Care Directory, and PayorID.com.   MHIS will enhance its classification rules to incorporate any variations that the final HIPAA regulations require.  Business needs of providers may require additional identification, particularly of “Parent” and health plan affiliates, therefore, MHIS will structure its files to continue to meet the business needs of providers.

We will also modify our interface to transmit the National Health Plan Identifier code to providers and our information partners. MHIS will also bid to serve as the National Health Plan Identifier Registry.  MHIS is currently performing the types of functions that the registry will need to perform.  MHIS also has information on the vast majority of health plans, and has an understanding of the business needs and structures of the healthcare providers. 

2. Health Care Providers:

Health care providers that utilize MHIS PayorID.com to access information on health plans will be positioned to efficiently implement the National Heath Plan Identifiers.  

If the provider is using the PayorID as a reference site to obtain contact information on health plans, the new National Health Plan Identifier codes will be available on the web site for input (integration) into the provider’s insurance master files.

If the provider is using the PayorID and has established a custom PayorID.com database, the new National Health Plan Identifier can be automatically downloaded to the provider’s system.

MHIS will provide the data elements to the providers so that they are compliant with the HIPAA Standards for the National Health Plan Identifier.   All information on the PayorID.com Web site, electronic interface files, and the MHIS Managed-Care Directory will be consistent with EDI standards.

The business needs of providers may require that they maintain systems to identify health plans by address.  The August 1998 HIPAA paper stated, “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.”  That may be true for the submission of claims but may not be true for the business operation and requirements of the provider for the following reasons.

First, over thirty percent of the patients do not have their Health Plan Identification Card at the time of service.  That card contains the National Health Plan Identifier.  Providers must have a system that allows its staff to identify the health plan and obtain the National Health Plan Identifier to use for manual or electronic verification, authorization, and claims submission, when a card is not provided.  Moreover, just having the National Health Plan Identifier will not appropriately assign the patient to the correct contract and payment value.  This will be particularly true, if the HIPAA regulations assign a single National Health Plan Identifier to all HMOs owned by the same “Parent” organization.  The provider will need to use the address of the plan to identify the particular HMO with which they contract.  Much of the time, only the local HMO has a contract with the provider and the special contact rates only apply to that local HMO.  Similarly, many PPO relationships for multiple PPO networks will not be appropriately captured by some of the current rules being discussed for HIPAA.  MHIS will provide the common identifier for use in electronic transmissions and an internal identifier, so that the provider can allocate the patient to the correct contract.

Providers that have access to the PayorID.com service will be able to deal most effectively with the implementation of HIPAA.

3. Information Partners and Health Care Clearinghouses:

MHIS will affiliate with electronic information exchange service companies that provide comprehensive electronic transaction services for authorization, eligibility, and claims submissions, between providers and health plans.

The exchange companies facilitate the electronic transactions.  MHIS facilitates maintaining the insurance master file for providers systems for all payors that the provider requires.  MHIS will also provide reference files for payors that the provider does not need to maintain its internal systems.

Providers are limited to submitting electronic transfers for those providers that are set up and coded in the providers system, and also coded and set up in the claims clearinghouse to accept electronic claims.  MHIS can assist providers and clearinghouses to improve the consistent generation and input of health plan data including, electronic identifier data prior to and after the adoption of a National Health Plan Identifier codes.

Hospitals over the course of a time will treat patients covered by almost every type of health plan available.  However, it is not cost effective or necessary for a provider to set up and code in its own system for the payors that are out-of-area.  MHIS, however; is setting up all health plans so that every provider can access consistent information on any payor. Accessing the MHIS PayorID.com database allows the provider to get information for transactions on patients and health plans that are not set up in its own insurance master file. That information can than be used by the clearinghouse to direct the electronic transaction to verify eligibility and authorization for the submitted claim.  When the MHIS information is not provided, the clearinghouse must fill in the information off-line or the service might not be verified for authorization.  Patient eligibility can therefore be denied or claims payment delayed.  The off-line verification by the clearinghouse may fail due to incorrect information collected and requires repeated contact, after the fact, between the facility, the clearinghouse, and health plans.   Forwarding information to the clerks on health plans that are not set up in the providers systems, enables them to compile the patient information prior to or while the patient is being seen.

Since HIPAA will not require all health plans to use electronic transactions and, clearinghouses will not cover electronic transactions to all health plans, MHIS provides a service to communicate standardized information on all payors to all providers.  Clearinghouses that affiliate with MHIS will have a mechanism to help their clients maintain files on health plans which frequently serve patients, health plans which are not frequently served, and health plans without electronic transactions codes.  Note: The MHIS PayorID.com service also provides the phone and contact information providers or clearinghouses need to resolve special cases or appeals. The PayorID.com site can also be used when a patient arrives without an ID card.

The MHIS web site can be integrated with the clearinghouse system. 

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Appendix

PayorID.com Features

MHIS compiles all the registry data on all payors.  The web site www.PayorID.com allows access to that data.

The MHIS PayorID.com system enables the clients to search on a number of different fields or combination of fields.  Data searches are available by numerous fields such as the payors, employers, third party administrators, networks, plan types, addresses, cities, states, zip codes, and benefit types.  To search for various data on a specific payor or network, enter the search criteria in the space provided and let the application do the research for you.  Sort capabilities are also available on one field at a time or any combination of fields.  Detailed information including electronic claims processing codes, such as, NEIC codes, IMS Codes, and managed care codes are also available.

The MHIS PayorID.com system is the most logical, cost-effective way for the provider’s business office to obtain and maintain managed care information.  The MHIS Managed-Care Directory will continue to be published, for all those without Internet access.  Larger facilities, medical groups or billing organizations can choose between the client-server version of the PHind Payors software or the PayorID.com service integrated with their other managed care systems and customized to the client’s needs.

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