Health Plan

Report
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 160.103
● Controlling health plan (CHP) vs. Subhealth Plan
(SHP)
Enumeration Requirements
Entity
Enumeration Requirements Enumeration Options
CHPs
Must get an HPID for itself


SHPs
Not required to get an
HPID


May get an HIPD(s) for its
SHP(s)
May direct its SHP(s) to get
HPID(s)
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 §162.103:
“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 selffunded (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
Scenario 1 (4x)
(
Current – 8 Payer IDs (prof/inst)
Future – 8/4 HPID with no prof/inst
Controlling Health
Plan
Scenario 2 (3x)
Current – 6 Payer IDs (prof/inst)
Future – 6 HPID with no prof/inst
Controlling Health Plan
Controlling Health Plan
**New payer IDs
(HPID) not used today
Subhealth Plan
** New payer IDs
(HPID) not used
today
Scenario 3 (5x)
Current – 10 Payers ID (prof/inst)
Future – 5 HPID with no prof/inst
Controlling
Health Plan
Scenario 4 (1x)
Current – 2 Payer IDs (prof/inst)
Future – 2/3 HPID with no prof/inst
Controlling Health Plan
Controlling Health Plan
**New payer IDs
(HPID) not used today
Subhealth Plan
*2,000+ ASO plans and ancillary plans not included.
**Which under the current rule could enumerate with HPID’s
**New payer IDs
(HPID) not used today
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:
http://www.cms.gov/Regulations-and-Guidance/HIPAA-AdministrativeSimplification/Affordable-Care-Act/Health-Plan-Identifier.html
Or
You may email CMS your HPID questions at:
[email protected]
Thank you,
Christol Green
[email protected]
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
MEDICARE J5
Part B Payer IDs are
 IA “05102”
 KS “05202”
 MO “05302”
 NE “05402”
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 2014
• 1 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
31
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.
32
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.
Recommendations for common usage of
enumeration process
33
• 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
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
Identify Controlling Health Plans
Legal Review & Approval
Collect Data
Register with CMS
Submit HPID Application
Obtain HPID Approval
Administrative Tasks
Communicate HPIDs to Internal
Partners
Communicate to External Partners
•Controlling health plans will be identified using Legal Entity Listing
•Legal will review and approve the list of controlling health plans and provide the
segment authorizing official for each
•Collect necessary information for entering the controlling health plan application into
CMS Health Plan Online Enumeration System (HPOES)
•Complete the registration as a Submitter in the CMS HPOE System
•Read and understand the HPOES manual
•Enter and Submit Controlling Health Plan HPID application
•HPID application is submitted and electronically routed (through email) to the
assigned UHG segment authorizing official
•Maintain complete list of the enterprise’s HPIDs
•Identify contacts for Business Units & Business Segments
•Business & IT Units & Segments
•Update payer ID list on unitedhealthcareonline.com
•Update OptumInsight
•Trading Partners, Providers and other vendors as required
Questions
Questions and Answers

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