Jim does bring up a valid concern from the payer perspective. It is true
that many/most health plans identify providers uniquely for each provider
contract relationship to price and pay claims faster and more accurately,
and many providers have multiple contracts in place at any given time.
However it would seem that the NPI (National Provider Identifier) will
obsolete that process and accordingly some payers are now looking at
alternative logic to ensure each claim is priced according to the terms and
conditions that apply to that patient and that provider. These changes
would include a more definitive review of member's benefits coupled to the
individual provider, if the services were rendered by an individual covered
entity and the organizational provider (usually the organizational
affiliation of the individual, e.g., group practice or clinic name/number).
If the provider is not an actual individual, the organizational NPI would
be used. However the individual NPI is critical because many provider
contracts are executed between individual providers -- not provider groups.
This information along with other information currently existing in the
transaction is presumably enough to properly process these transactions.
Bruce
"Rachel
Foerster" To: <[EMAIL PROTECTED]>
<[EMAIL PROTECTED] cc:
etcom.com> Subject: RE: Using a hybrid DNS
02/13/2002
03:28 PM
Please
respond to
rachelf
Kepa,
At the Seattle ad hoc discussion Jim Moynihan also brought up an issue re
identifiers - and that is that for many payers a provider may be associated
to many different plans (planID) and today, such a payer assigns the
provider a different provider ID for each plan. Thus, the provider must not
only know the payer ID, but also the plan ID and the provider ID assigned
to
it by the payer for a specific plan.
It's for this reason that I'm asserting that the issue of identifiers is
not
solely at the Interchange domain, but also in the transaction content
domain
as well, since we know that clearinghouses and other service entities today
aggregate claims from many different providers into a single transaction
which is forwarded to the payer.
I hope that Jim will seize this opportunity to provide us with other
scenarios around which requirements can be developed.
Rachel
-----Original Message-----
From: Kepa Zubeldia [mailto:[EMAIL PROTECTED]]
Sent: Monday, February 11, 2002 5:29 PM
To: [EMAIL PROTECTED]
Cc: WEDi/SNIP ID & Routing
Subject: Re: Using a hybrid DNS
William,
As it turns out, it is likely that my local BCBS will have a good number
of PlanIDs under HIPAA. Perhaps in the hundreds, as Regence BCBS has a
multitude of plans in several states.
A provider that sees a HIPAA PlanID and has a connection with a
clearinghouse as well as a connection with REgence BCBS will have to
determine whether the transaction goes to REgence BCBS or to the
clearinghouse that acts as "gateway to the rest of the world".
Today we are not yet using PlanIDs, but PayerIDs. With PayerIDs life is
a lot easier because Regence BCBS will have only one Payer ID. But,
with PlanIDs Regence would have a good number of health plan under
administration, each one with its own PlanID, indistinguishable from any
other PlanID out there. The same will happen to all other payers.
Can you imagine the confusion if we don't have a good way to map from
PlanID to Payer?
Kepa
William J. Kammerer wrote:
> Chris:
>
> I'm just a populist at heart!
>
> But I'm also a little confused! If you (a provider) have a standard
> claim transaction intended for a particular National plan ID, say
> 987654321, you would build a single 837 with the payer (or plan?)
> indicated in the NM1 within the 2010BB loop. You would not comingle
> claims for multiple payers or plans, like a CH might (as Bob Poiesz has
> illustrated).
>
> So, who else's ID - other than the payer's - would be in the ISA
> receiver field? There does seem to be a relationship when standard
> transactions go from provider to payer, unmolested, via a VAN or EDIINT
> software. I suppose if you've been told, via Kepa's "directory," that
> claims for PlanID 987654321 go to WebMD, WebMD might demand that their
> ID be in the ISA receiver field - but yet, they already know they're the
> receiver! In that case, it's almost irrelevant what's in the ISA
> receiver field - WebMD sounds like they're going to strip search the 837
> anyway in order to combine your claims with those of other providers
> intended for whatever TPA or Payer handles PlanID 987654321.
>
> William J. Kammerer
> Novannet, LLC.
> +1 (614) 487-0320
>
>
> ----- Original Message -----
> From: "Christopher J. Feahr, OD" <[EMAIL PROTECTED]>
> To: "William J. Kammerer" <[EMAIL PROTECTED]>; "WEDi/SNIP ID &
> Routing" <[EMAIL PROTECTED]>
> Sent: Saturday, 09 February, 2002 07:46 PM
> Subject: Re: Using a hybrid DNS
>
>
> William,
> Thanks for your ongoing concern for us "little people (providers)", but
> the more I think about divorcing the payor/plan ID info in the
> transactions from the receiverID info in the ISA, the more I like it...
> because it embraces the models in use today in which there really is no
> relationship between these two addresses. If the industry is willing to
> adopt the distributed address directory model that Kepa is proposing,
> then the "little people" can either hound their office system vendors to
> include that capability... or the smart vendors will see the business
> opportunity and sell the address discovery process to the provider as a
> value-add...or the small provider can just shovel all of his claims to
> one clearinghouse and let the CH worry about routing them. Since the
> need to know where to send these interchanges is going to be so acute
> for the provider, I can't imagine a situation in which no one was
> willing to create a system that would do the address discovery for them.
>
> -Chris
