Presentation on theme: "WEDI Summer Forum July 25, 2014 HIPD – Enumeration Schemas Moderator Michael Ubl (Ubl Consulting, LLC)"— Presentation transcript:
WEDI Summer Forum July 25, 2014 HIPD – Enumeration Schemas Moderator Michael Ubl (Ubl Consulting, LLC)
Agenda ● Enumeration Schema Overview (per CMS) ● Topics to consider in developing an Enumeration Schema strategy ● Panel Discussion – Laurie Burckhardt (WPS) – Christol Green (WellPoint, Inc.) – Shelagh Kalland (Blue Cross Blue Shield Minnesota) – Kim Peters (Humana) – Jeff Ziel (United Health Care) – Carolyn Besch (United Health Care)
Who is Required to Get the HPID? ● Health plans as defined by 45 CFR ● Controlling health plan (CHP) vs. Subhealth Plan (SHP) Enumeration Requirements EntityEnumeration RequirementsEnumeration Options CHPsMust get an HPID for itself May get an HIPD(s) for its SHP(s) May direct its SHP(s) to get HPID(s) SHPsNot required to get an HPID May get an HPID at the direction of its CHP May get an HPID of its own initiative
Controlling Health Plan Controlling Health Plan (CHP): ● A CHP means a health plan that controls its own business activities, actions, or policies Or is controlled by an entity that not a health plan; and ● If it has sub health plans(s) exercises sufficient control over the sub health plan(s) to direct its/their business activities, actions or policies
Subhealth Plan Subhealth Plan (SHP): ● A SHP means a health plan whose business activities, actions or policies are directed by a controlling health plan
Regulatory Schedule for Health Plan Enumeration ● Large Health Plans must complete the enumeration process by November 5, 2014 ● Small Health Plans (less than $5 million in revenue) must complete the enumeration process by November 5, 2015
HPID Enumeration Schema Considerations ● Corporate structure ● Product / benefit package structure ● Interpretation of the terms ‘payer’ vs ‘health plan’ ● Geographic presence (local, state, region, national) ● Transaction usage ● Relationship with self-funded groups ● Access and intended use of the Health Plan and Other Entity Enumeration System (HPOES)
Health Plan Identifier (HPID) Enumeration Schema WEDI Summer Forum – July 25, 2014 Christol Green Sr. Business Consultant, E-Solutions I Strategy and Standards Governance I WellPoint Inc
Agenda Key Definitions HPID Facts or Fiction HPID Enumeration Determination Who must enumerate Issues across Payers Enumeration will be at granular level (not in sync with Payer IDs) CMS Enumeration Systems experience/challenges Issues with Self-funded and Fully-Insured
Key HPID Definitions The following definition are found in 45 CFR §160: “Health Plan” means an individual or group plan that provides, or pays the cost of, medical care (definition also includes a list of types of health plans). The following definitions are found in amended 45 CFR § : “Controlling Health Plan (CHP)” means a health plan that: controls its own business activities, actions or policies; or is controlled by an entity that is not a health plan and if it has a subhealth plan(s), exercises sufficient control over the subhealth plan(s) to direct its/their business activities, actions or policies. WellPoint interpretation is CHP must enumerate and obtain a HPID. “Subhealth Plan (SHP)” means a health plan whose business activities, actions or policies are directed by a controlling health plan. WellPoint interpretation is SHP may or may not enumerate.
HHS CHP Guidance In the final rule put out by HHS, the Department suggests these questions to decide if an entity is a CHP: Does the entity itself provide or pay for medical care? Does either the entity itself or a non-health plan organization control the business activities, actions, or policies of the entity? If the answer to both questions is ‘‘yes,’’ then the entity would meet the definition of CHP.
Key HPID Definitions Other defined terms include: “Administrative Services Only (ASO)” is a type of health plan where the employer or other group sponsor is financially responsible for paying plan expenses such as members’ claims; the insurance company only provides administrative services. This is also called “Self‐Funded” or “Self‐Insured.” “Third Party Administrator (TPA)” is an organization that processes insurance claims or aspects of an employee benefit plan for employers that self-insure its employees. The employer acts as an insurance company and underwrites the risk. WellPoint interpretation is TPA is generally not a health plan and would not be required to enumerate even though in some situations a TPA may also be a health plan e.g., when an insurance company acts as a TPA.
HPID Fact or Fiction HPID topics circulating within the industry…. HPID Enumeration Controlling health plans are required to obtain an HPID, even if they do not engage in standard transactions.-- FACT A subhealth plan is not required to get an HPID (but their controlling health plan may ask or require them to do so). -- FACT There is no charge for obtaining a HPID. -- FACT Payers are permitted to complete a HPID application for self- funded (ASO) customers. -- FICTION
HPID Fact or Fiction HPID use in HIPAA electronic standard transactions The HPID does not replace the Payer ID used in HIPAA electronic standard transactions. -- FACT The HPID is not used for routing purposes of HIPAA electronic standard transactions. -- FACT
Enumeration Determination Since the X12 implementation guides (837s, 835) will require a new Addenda version, all translator software and editors will have to be updated or all transactions may fail HIPAA edits. With the new notes in the transactions to support HPID and Payer ID, it will also create new rules for translators and HIPAA editors. Industry needs to define implementation/testing strategy. Need to standardize the HPID enumeration or current Payer ID (no change) distribution/communication strategy Need better industry communication of Health Plan Identifier vs Payer ID and OEID usage.
Common Issues across Payers HPID Enumeration at granular level (not 1 for 1 – Payer ID to HPID) Self-Funded/Self-Insured groups need guidance and payers are concerned since they are our customers. What is the intended/future use of HPID/OEID numbers other than in X12 transactions Is there a gap that we are trying to correct today within electronic HIPAA standard transactions?
Other Enumeration Issues Different definition of controlling health plan between payers (SHP, ASO, TPA etc…?) Different relationships with Self-Funded groups across health plans Delegated provider groups that may qualify as controlling health plans. Different legal interpretations across health plans Different corporate structures across health plans
Considerations Recommendations for common usage of enumeration process: Define who needs to actually enumerate within your Corporate Structure i.e. Controlling Health Plan(CHP), Sub Health Plan(SHP), Self-funded Groups, Fully-insured ? Build out a model that can show the different relationships that make up why one entity is a controlling health plan and why another is not. Determine level of enumeration: CHP/s only CHP/s and SHP/s only CHP/s, SHP/s and others
HPID Enumeration * Payer ID vs. HPID Controlling Health Plan Subhealth Plan ** New payer IDs (HPID) not used today Scenario 1 (4x) ( Current – 8 Payer IDs (prof/inst) Future – 8/4 HPID with no prof/inst Controlling Health Plan **New payer IDs (HPID) not used today Scenario 2 (3x) Current – 6 Payer IDs (prof/inst) Future – 6 HPID with no prof/inst Controlling Health Plan Scenario 3 (5x) Current – 10 Payers ID (prof/inst) Future – 5 HPID with no prof/inst Controlling Health Plan **New payer IDs (HPID) not used today Subhealth Plan **New payer IDs (HPID) not used today Scenario 4 (1x) Current – 2 Payer IDs (prof/inst) Future – 2/3 HPID with no prof/inst * 2,000+ ASO plans and ancillary plans not included. **Which under the current rule could enumerate with HPID’s
CMS Enumeration Systems 3 steps to gain access for HPID submitter, approver or user CMS Portal Access HIOS Access – registration application HPOES Access – registration application HPOES Experience Gaining HIOS/HPOES access can be time-consuming Creating service tickets for everyone of our Health Plan ID submitters and approvers to gain access after they completed their registrations Resolving service tickets took 10 days – 3 weeks to resolution
CMS Enumeration Systems experience/challenges During our Phase 1 HPID application process of our Controlling Health Plans, one of our plans was stuck in “limbo” caught between submitter and approver. That ticket was resolved 2 weeks after submission We also identified minor issue within the HPID application process When submitter cut and pasted plans’ NAIC number into the HPID application, the approver received a different plans’ NAIC number. The plans’ NAIC number was changed.
Issues with Self-funded and Fully-Insured Issues with Self-funded and Fully-Insured Plans We are concerned about the lack of awareness of our customers with self-funded and fully-insured plans about the HPID and upcoming certification requirements We have done what we can to educate and answer questions, but CMS needs to provide more education and guidance. There remain many questions and issues which only CMS can resolve, such as whether fully-insured group health plans must obtain HPIDs separate from the health insurers which supply them with health insurance. We understand that many group health plans are awaiting further information before they enumerate, which may create a time crunch closer to the compliance period. As we get closer to the enumeration deadline, having clear answers becomes more critical.
CMS has issued some FAQs and you may find HPID information at: Simplification/Affordable-Care-Act/Health-Plan-Identifier.html Or You may CMS your HPID questions at: Thank you, Christol Green
HPID Enumeration WPS Enumeration Laurie Burckhardt, EDI Manager, WPS Health Insurance
WPS at a Glance WPS Commercial WPS Health Insurance’s (WPSHI) Payer ID is “WPS” ● Covers the following types of contracts – Individual – Group – Self-Insured (50+) – Family Care contracts (4+) Arise’s Payer ID is “ARISE” ● Covers the following types of contracts – Individual – Group EPIC’s Payer ID is “EPC” ● Covers the following types of contracts – Individual
WPS at a Glance TRICARE TRICARE For Life’s Payer ID is “TDFIC” Overseas’ Payer ID is “FOREN” VAPC3’s Payer IDs are “VAPCCC5A”, “VAPCCC5B”, “VAPCCC3” AND “VAPCCC6”
WPS at a Glance MEDICARE MEDICARE J5 Part B Payer IDs are IA “05102” KS “05202” MO “05302” NE “05402” MEDICARE J5 Part A Payer IDs are IA “05101” KS “05201” MO “05301” NE “05401” J5 National “05901” MEDICARE J8 Part B Payer IDs are IN “08102” MI “08202” MEDICARE J8 Part B Payer IDs are IN “08101” MI “08201”
The plan as of July HPID for WPS Health (individual & group plans) WPS Employee Group Not Included Self-Funded Groups Family Care 1 HPID for Arise 1 HPID for EPIC TRICARE & MEDICARE – on hold
Considerations Determined enumeration strategy based solely on definition. Subhealth Plan Saw no benefit to use at this time Preference is not to use in the transactions WPS is a payer not a health plan Plan to inform self-funded groups of HPID to ensure that they are aware of what is needed.
Humana WEDI HPID Enumeration Strategy Enumeration Characteristics Kim Peters HIPAA EDI Program Manager July 2014 Insert form number via Header and Footer option or delete, if not needed
Humana Issues considered What Transactions are currently using Controlling Health Plan in identified X12 fields? What Humana legal business entities are currently in business and using X12 transactions? Which of those legal entities qualify for a HPID vs OEID Enumeration at granular level (not 1 for 1) Legal interpretation is different than what CMS had envisioned Self-Funded groups need guidance and payers are concerned since they are our customers. 31
Non-Common Enumeration Issues Different definition of controlling health plan between payers (SHP, ASO, TPA etc…?) Different relationships with Self-Funded groups across health plans – Can we legally give guidance to Self-Funded Groups – What is the best way to distribute information to Self-Funded groups without implying guidance. 32
Recommendations for common usage of enumeration process Define who needs to actually enumerate i.e. Self-funded Groups, Health Plans, Delegated Provider Groups?? Build out a model that can show the different relationships that make up why one entity is a controlling health plan and why another is not. Work with CMS to develop a communication process for Self-Funded groups 33
HPID HPID – Blue Cross and Blue Shield of MN Shelagh Kalland, Director
HPID Start with current state Evaluate what you do today Does it meet the intent of the regulation? Start simple We started with 1 as we use only 1 today Worked with legal and business areas to gain agreement We ended with 3
Blue Cross Blue Shield of MN HPIDs 3 HPIDs will be requested Blue Cross Blue Shield of MN – Blue-branded business (individual, small group, and group business) Comprehensive Care Services, Inc – Non-branded TPA business BlueLink TPA – Blue-branded TPA
HPID –Self-Insured Groups Communicate the requirement Offer more information where appropriate Recommend legal review/input Group is responsible for final decision Group is responsible for applying for HPID if needed
HPID Enumeration UnitedHealth Group Enumeration Jeff Ziel, Administrative Simplification Program Director, UnitedHealth Group
HPID Challenges and Considerations Determine UHG’s Legal Entities Determine UHG’s Controlling Health Plans – Who is impacted Determine which transactions include identification of Controlling Health Plans within the transaction – By Health Plan – By Platform / System Determine impact to self-funded groups – Include Legal, Compliance, CMS, Industry
HPID Enumeration Approach 1 Enumerate the required Health Plans in order to comply with the HHS final rule: – UnitedHealth Group’s 75 Controlling Health Plans will obtain HPID from the Health Plan and Other Entity Enumeration System (HPOES) by November 5, 2014 Advantages: – The ruling is vague, delaying enumeration and development outside of the minimum required for compliance may be appropriate. – The only required use of HPID is that a covered entity must use an HPID to identify a health plan that has an HPID in the standard transactions where the covered entity is identifying a health plan in the standard transaction. – The final rule does not require that health plans be identified in the standard transactions if they were not identified before this rule. – Enumeration system, HPOES, data requirements are not complete – Reduces input and maintenance in HPOES – Least impact to providers and our trading partners
HPID Enumeration Approach 2 Enumerate UHG’s 75 Controlling Health Plans as required in order to comply with the HHS final rule: – Controlling Health Plans will obtain HPID from the Health Plan and Other Entity Enumeration System (HPOES) by November 5, 2014 – UHG Internal Business Segments determine if business gains operational efficiency by enumerating Other Entities – Advantages for Option 2: Allows health plans to determine enumeration based on their business needs May position us for future use of HPID & OEID – Disadvantages for Option 2: May not meet future use of HPID and OEID Will require additional maintenance in the HPOES Could be disruptive to our providers and trading partners May increase development cost and ID card cost
HPID Enumeration Approach 3 Eliminate usage of Payer IDs or other identifiers in our covered transactions. Enumerate all entities that may be identified in covered transactions: – All Controlling Health Plans will obtain HPID – All Sub-Health Plans that are identified in covered transactions will obtain and use a HPID – All Other Entities that are identified in covered transactions will obtain and use an OEID – Advantage for Option 3: May position us for future use of HPID and OEID – Disadvantages for Option 3 Vague ruling and risk that subsequent or other related rulings may require different enumeration approach. May result in other entities that are not required to obtain IDs obtaining IDs (HPID or OEID) that will not be utilized. Complex to maintain in the HPOES system Will be disruptive our providers and trading partners
HPID Enumeration Strategy Assess Current State – 75 CHPs – 4 SHPs – 269 Other Entities Reviewed HPID Ruling – Input from legal counsel – Governance committee and steering committee Proposed recommendation to Enumeration – Solution option 1 Build schedule of activities
HPID Enumeration Process Controlling health plans will be identified using Legal Entity Listing Identify Controlling Health Plans Legal will review and approve the list of controlling health plans and provide the segment authorizing official for each Legal Review & Approval Collect necessary information for entering the controlling health plan application into CMS Health Plan Online Enumeration System (HPOES) Collect Data Complete the registration as a Submitter in the CMS HPOE System Read and understand the HPOES manual Register with CMS Enter and Submit Controlling Health Plan HPID application Submit HPID Application HPID application is submitted and electronically routed (through ) to the assigned UHG segment authorizing official Obtain HPID Approval Maintain complete list of the enterprise’s HPIDs Identify contacts for Business Units & Business Segments Administrative Tasks Business & IT Units & Segments Update payer ID list on unitedhealthcareonline.com Update OptumInsight Communicate HPIDs to Internal Partners Trading Partners, Providers and other vendors as required Communicate to External Partners