Do You Have Your Health Plan Identifier (HPID)?

Brief Summary

Under the Affordable Care Act (ACA) the Department of Health and Human Services (HHS) must create a series of rules over a five year period, designed to help streamline health care administrative transactions, prompt greater use of standard processes by health care providers and smooth current work processes.

Because of this requirement, HHS created a national unique health plan identifier (HPID) requirement in September of 2012. Essentially, health plans must “certify” that they are following aspects of the Health Insurance Portability and Accountability Act (HIPAA). The rules on how to apply and obtain HPIDs differ for each type of health plan. The HPID requirement is intended to replace proprietary identifiers that have been used by health plans and vary greatly, which may not be accommodated in standard transaction data field or be as accurate.

The HPID is a 10 digit number assigned by the Centers for Medicare & Medicaid Services (CMS) to the health plan.   The company itself is in charge of obtaining this number, and not the insurer. It will be used to simplify the routing, review and payment of electronic HIPAA transactions such as medical and dental claims, benefit enrollment, and claims statuses.   The HPID will not replace the Payer ID used in HIPAA electronic standard transactions and it is not used for routing purposes.

A controlling health Plan (CHP), including a self-insured CHP, is required to obtain an HPID. A CHP is a health plan that controls its own business activities, or is controlled by an entity that is not a health plan. In contrast a subhealth plan (SHP), which is a health plan whose business activities are directed by a controlling health plan, is not required to obtain an HPID but could at the direction of its CHP or own its own initiative.   The CHP can obtain a HPID for its SHP.

A similar system is in place for non-health plan entities. A non-health plan entity that must be identified in standard transactions (like a TPA) is permitted, but not required, to obtain an Other Entity Identifier (OEID). The OEID is for non-health plan entities that don’t fit into the HPID group but must be identified.

Plans that Must Comply

  • Self-funded (ASO) health plans and fully-insured health plans with more than 50 employees.
    • Fully insured HRA accounts with 50 or more participants are considered self-funded health plans as they are funded by employer. They must comply with the HPID requirement.
  • Plans with health benefit receipts of more than five million dollars, or “large” health plans.   They will need to get an HPID by November 5, 2014.
    • Controlling health plans (CHPs) must get an HPID
    • Subhealth plans (SHPs) are not required to get an HPID but can be required to do so by their CHPs.
  • Plans with health benefit receipts under five million dollars, aka “small health plans.” They will need to get an HPID by November 5, 2015.
  • Health plans must use HPIDs in HIPAA electronic standard transactions by November 7, 2016.

Deadlines

  • November 5, 2014: Large health plans must have HPID number.
  • November 5, 2015: Small health plans must have HPID number.
  • November 7, 2016: Large and small health plans, healthcare clearinghouses, and covered healthcare providers must use HPID in standard transactions.

How to Apply

A national enumeration system assigns unique HPIDs to eligible health plans via on online application process that was opened up on March 29, 2014. Navigating this process is explained on the CMS website and a HPID User Manual.

Here is a brief overview of the application process[i]:

  1. Register the Organization in HIOS.
  2. Access HIOS User Role Management.
  3. Access HPOES and Select an Application Type.
  4. Complete and Submit an Application.
  5. Application Review by the Authorizing Official.
  6. HPID Number Assigned.

1. Register the Organization in HIOS.

To determine if the organization already exists in HIOS, search by the organization’s Federal Employer Identification Number (EIN). If the organization does not already exist in HIOS, users will need to register their organization and are reviewed prior to approval. The information needed to register a new company includes:

    • Company Legal Name
    • Federal Employer Identification Number
    • Incorporated State
    • Domiciliary Address

If the organization already exists in HIOS, users can move to step 2.

2. Access HIOS User Role Management.

Users must determine their user role and identify the company to which they need access. There are three different HPOES user roles:

    • Guest User: a user that is able to view general HOPOES information (no company association needed).
    • Submitter User: A representative of health plan or other entity that submits an application.
    • Authorizing Official User: A company executive that has the authority to approve applications, including CEOs and CFOs.
      • If requesting the Submitter or Authorizing Official role, users must identify the company to which they want access to.
      • Users can only have one HPOES role at a time.

3. Access HPOES and Select an Application Type.

There are two different HPID application types, CHP and SHP. Users completing a SHP HPID application must select a CHP company.

4. Complete and Submit an Application.

During the completion of the application, the company’s Authorizing Official needs to be identified if one hasn’t been designated already. SHP applications will display the CHP’s Authorizing Official Information. All Authorizing Official information provided in the application is reviewed prior to the user being assigned the Authorizing Official role.

For CHPs:

Users are able to review their application before submission. Generally, here are the types of information needed for this step:

  • Company Information: Company Name, Federal Employer Identification Number and Domiciliary Address.
  • Authorizing Official Information: First and Last Name, Title, Phone Number and Email Address.
  • Health Plan’s NAIC Number or Payer ID used in standard transactions.

For SHPs:

There are two different ways to apply for a SHP HPID: selecting the “Apply for SHP HPID(s)” button on the HPOES Submitter Homepage or on the CHP Profile Page.

Subhealth Plan Type: Company

The SHP Company information needed includes:

  • Company Information: Company Name, Federal Employer Identification Number and Domiciliary Address.
  • Health Plan’s NAIC Number or Payer ID used in standard transactions.

Subhealth Plan Type: Issuer

The SHP Issuer information needed includes:

  • Company Information: Company Name, Federal Employer Identification Number and Domiciliary Address.
  • Issuer’s HIOS ID, Issuer Legal Name and State of Business (but is the Issuer does not already exist in HIOS, users will need to register the Issuer first).
  • Health Plan’s NAIC Number or Payer ID used in standard transactions.

Subhealth Plan Type: Product

The SHP Product information needed includes:

  • SHP Company Information: Company Name, Federal Employer Identification Number, and Domiciliary Address.
  • HIOS Issuer ID, Issuer Legal Name and State of Business.
  • HIOS Product ID, Product Name, Product Type and Market Type.
  • Health Plan’s NAIC Number or Payer ID used in standard transactions.

Subhealth Plan Type: Line of Business

The SHP Line of Business information needed includes:

  • SHP Company Information: Company Name, Federal Employer Identification Number, and Domiciliary Address.
  • Line of Business Type.
  • Product Name/Brand Name.
  • Health Plan’s NAIC Number or Payer ID used in standard transactions.

Subhealth Plan Type: Other Category

The SHP Other Category information needed includes:

  • SHP Company Information: Company Name, Federal Employer Identification Number, and Domiciliary Address.
  • Other Category Name.
  • Other Category Type/Description.
  • Health Plan’s NAIC Number or Payer ID used in standard transactions.

5. Application Review by the Authorizing Official.

Upon submitting of the application, the company’s Authorizing Official will be notified that an application is pending their approval. The Authorizing Official will need to review each application and will have the option to approve or reject it.

6. HPID Number Assigned.

Once the application is approved by the Authorizing Official, the system will generate an HPID and an email notification will be sent to the submitter user.

Potential Issues:

There is the potential for a fully-insured SHP that is part of a larger wrap plan to have two HPIDs if employers, carriers and TPAs do not communicate who is obtaining the HPID. Coordination is key to prevent this mistake.

Other unknowns still exist in the implementation of HPIDs. These include how mistakes can be fixed, how CHP and SHP will communicate information, and what responsibilities CHPs and SHPs respectively have. Additional guidance is expected to emerge as the compliance deadline to utilize these HPIDs comes closer.

[i] *Information taken from

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

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About Andie Schieler

Andie is an attorney and works in J.W.Terrill's Compliance division specializing in interpreting the Affordable Care Act and various insurance laws. She advises clients on legal and regulatory issues affecting their employee benefit plans. She obtained her law degree from Saint Louis University and undergraduate from Indiana University Bloomington.

View all posts by Andie Schieler

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