I asked Chris Feahr Saturday: "So, who else's ID - other than the payer's - would be in the ISA receiver field?" when "standard transactions go from provider to payer, unmolested..."
The exchange below, on HIPAAlive, from Ken Fody, answers the question. A self-funded employer group health would be administered by a third party (TPA) - claims and whatnot obviously would not be sent from the provider to the payer (the employer), but to the TPA. Not only would the payer in this case not want to have the stuff sent to it (after all, it outsourced the grunt work to the TPA), but it probably isn't even allowed to see the stuff since it isn't a HIPAA covered entity. When National Plan IDs materialize, then the plan could be identified within the transaction set. But that plan ID could not be used in the ISA, since there's no provision for qualifying the plan ID using the allowable codes in the Interchange ID Qualifier. If the ISA were able to address a plan ID, then routing of the interchange might be accomplished automatically looking only at the ISA - using Kepa's DNS directory, 987654321.PlanID.hipaa.net would ultimately point you to the TPA (or the clearinghouse it uses). But in the meantime, I guess the provider could place the ID (DUNS?) of the TPA in the ISA receiver field. Are TPAs generally carriers themselves? - in that case their NAICs would be available. All this points out, I believe, that we need a list of all "information flows," starting with the simplest and progressing to the complicated with TPAs and intermediaries. We could use Dave Minch's "nomenclature" or formulae, e.g., Claim: provider ---> prov's CH ---> payer's CH ---> payer Remittance: payer ---> prov's CH ---> provider When Chris volunteered to serve as keeper of the definitions, he added: "please feel free (whole group) to throw any terms and definitions in my direction as they occur to you." Now another has come up: do we need to add sponsor to the glossary, in order to distinguish an employer who's a payer from the employer paying insurance premiums to a Health Plan? William J. Kammerer Novannet, LLC. +1 (614) 487-0320 ----- Original Message ----- From: "Fody, Kenneth W." <[EMAIL PROTECTED]> Sent: Friday, 08 February, 2002 05:32 PM Subject: RE: TCS: Payer Name Be cautious when you mention the NAIC (National Association of Insurance Commissioners) number and payers. Only licensed carriers (ins. cos., Blue Plans, and HMOs) have NAIC numbers. If the entity is not a licensed carrier (e.g. a TPA and/or group health plan) then it will not have an NAIC number. How often does that happen? Well, 50% of the people in this country have coverage through a self-funded plan. Therefore, the number of folks presenting themselves who have coverage processed by an entity that does not have an NAIC number can be significant. With regarding to the National Payer ID, HHS has not even issued a draft regulation yet. So the ultimate solution is not close to coming. Ken Fody Independence Blue Cross -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] Sent: Wednesday, February 06, 2002 2:36 PM To: HIPAAlive Discussion List Subject: [hipaalive] RE: TCS: Payer Name *** HIPAAlive! From Phoenix Health Systems/HIPAAdvisory.com *** Payers do have a NAIC number, which may be used. Some clearing houses use our NAIC number to send claims to us. Some clearing houses use their own number that they assign to us. We are waiting to see what the government is going to assign to us. For information go to the following site. http://aspe.hhs.gov/admnsimp/bannerid.htm Peggy Drake Midwest Security -----Original Message----- From: Catherine Lohmeier [mailto:[EMAIL PROTECTED]] Sent: Wednesday, February 06, 2002 12:57 PM To: HIPAAlive Discussion List Subject: [hipaalive] RE: TCS: Payer Name *** HIPAAlive! From Phoenix Health Systems/HIPAAdvisory.com *** Don't the payers have an id number for themselves? Often large complex entities will have different payer id numbers which make it easier to sort claims electronically.