As part of the effort to standardize health plans’ electronic transactions, all group health plans are required to obtain a health plan identifier (HPID). The HPID is a 10-digit number assigned to health plans and will be used to identify the plan in standard transactions. Proposed regulations about the HPID were issued by HHS on April 27, 2012. Final regulations followed shortly after on September 5, 2012. Large health plans must obtain a HPID by November 5, 2014. Small health plans with less than $5 million in benefits per year have a one year extension and must obtain a HPID by November 5, 2015.
If a plan is fully insured, the insurance carrier is responsible for obtaining the HPID. If a plan is self-insured, the plan sponsor must obtain the HPID. If a plan sponsor’s health plan has both fully-insured and self-insured options, or has multiple self-insured options, the plan sponsor may obtain one HPID as the controlling health plan. Plans must apply for HPIDs at https://portal.cms.gov/wps/portal/unauthportal/home/. CMS has resources available to assist plans through the application process. For assistance in determining whether your plan is required to apply for an HPID or for assistance with the application process, please contact The McKeogh Company.
Who Needs to Apply for an HPID?
The regulations categorize plans based on the level of control the plan has over its activities as either a Controlling Health Plan or a Subhealth Plan. Under the regulations, a Controlling Health Plan (CHP) is required to obtain an HPID whereas a Subhealth Plan (SHP) may obtain an HPID but is not required to do so. A CHP may obtain an HPID on behalf of a SHP.
A CHP is a health plan that controls its own business activities, actions or policies. It can also be a health plan that is controlled by an entity that is not a health plan. This includes self-insured plans that satisfy the definition of a CHP. A SHP is a health plan whose business activities, actions or policies are directed by a CHP.
If a plan is fully insured, the insurance carrier is responsible for obtaining the HPID. If a plan is self-insured, the plan sponsor must obtain the HPID. If a plan sponsor’s health plan has both fully-insured and self-insured options, or has multiple self-insured options, the plan sponsor may obtain one HPID as the controlling health plan.
HIPAA’s definition of health plan is broad and includes any individual or group plan that provides, or pays the cost of, medical care. This would include dental and vision coverage as well as flexible spending accounts and health reimbursement accounts. Plans that are not subject to HIPAA’s administrative simplification rules are not required to obtain an HPID, including disability plans and workers’ compensation.
Large health plans must obtain an HPID by November 5, 2014 and small plans must do so by November 5, 2015. For this purpose, a small health plan is defined as a health plan which pays less than $5 million in benefits per year.
How to Obtain an HPID
Plans must apply for HPIDs using HHS’s Health Plan and Other Entity Enumeration System (HPOES) which is maintained by CMS’s Health Insurance Oversight System (HIOS). Users are required to register through the CMS Enterprise Portal at https://portal.cms.gov/wps/portal/unauthportal/home/. Users must sign up as individuals and request to be linked to the relevant plan. The user selects whether the application is for an HPID or Other Entity Identifier (OEID), which may be obtained by entities such as third party administrators (TPAs) who are not required to obtain HPIDs. The information requested in the application includes sponsor information, authorizing official information and the plan’s NAIC number or payer ID for standard transactions. Health plans will use the plan sponsor’s EIN for the payer ID. After the information is submitted, an authorizing official within the plan must approve the application. CMS has resources available to assist plans through the application process.
How is an HPID Used
All health plans are required to use the HPID in standard transactions by November 7, 2016. This requirement also applies to business associates when they conduct standard transactions on the behalf of a covered entity. Standard transactions include, but are not limited to:
- health care claims
- eligibility for a health plan
- health care claim status
- enrollment and disenrollment in a health plan
- health care electronic funds transfer and remittance advice
- health plan premium payments
- coordination of benefits
There are also some uses where an HPID may be used, though not required. HPIDs may be used in internal files, to help with processing transactions, on an enrollee’s insurance card, as a cross-reference in health care fraud and abuse files, in patient medical records, in electronic health records to identify health plans, in health insurance exchanges and for public health data reporting purposes.
Other Entity Identifiers
The HPID regulations also allow non-health plan entities that engage in standard transactions to obtain an Other Entity Identifier (OEID). The users who may obtain an OEID include third-party administrators, transaction vendors, clearinghouses and other payers. These entities are not required to obtain an OEID though a health plan may require their business associates to obtain OEIDs, especially those business associates who handle eligibility or claim status issues on the plan’s behalf. Because obtaining an OEID is voluntary, there is no required compliance date.