Doug Renshaw was kind enough to respond to my pleas from 15 March for information on how folks currently (or will) handle the ISA and GS for routing standard transactions; he has graciously agreed to let me pass on Highmark's plans as grist for discussion. Other than Doug, only Tim Collins and John Bristor have responded. Tim divulged some information on how Kentucky Medicaid might be handling IDs, and John Bristor shared what appears to be some kind of Medicaid EOB with strange and wondrous proprietary IDs. At this rate, I don't have too much to work from: I hate to nag, but with the hundreds of people on this list, surely some more folks could throw information my way so Ron Bowron and I can do a "proper" requirements analysis.
Doug said that Highmark will require that its NAIC code (54771) be submitted as the Receiver ID in the ISA. In the GS, he will require the NAIC of the payer that the transaction applies to, which could be that of Highmark or several other associated payers. NAIC codes are 5 characters, and the GS receiver ID can have a payer-defined 3 character suffix applied to the NAIC. In some cases, they will use a Highmark-assigned alpha suffix to manage internal routing requirements of stuff within the same payer. For the Sender ID in both the ISA and GS, Highmark requires the use of a proprietary trading partner ID. For transactions coming from a Clearinghouse, they'll have a trading partner ID for the clearinghouse which will be tied to individual providers. Also, Highmark requires a logon and password to connect to its network for sending and receiving EDI files. Highmark is considering use of the Internet to replace its dial-in network, but use of a logon and password would still be required. Highmark will only accept standard transactions, and only for a set list of payers who are in the Highmark "family". If a provider attempts to send transactions to payers not on Highmark's list, they will be rejected. Highmark is not attempting to offer providers a "portal" for submission of their claims to any and all payers - only a means of getting claims directly to itself and several of its subsidiaries. Doug does agree with my belief (by reading the NPRM) that payers will have to offer providers a direct "portal," or else will have to contract with a clearinghouse to collect standard transactions for them. As for Highmark's use of NAIC suffixes in the GS, they spell out some specific uses for particular transactions as required for internal routing and processing purposes. Specifically, Highmark will require a "V" on vision claims, and for institutional claims, they will require a "W" if the institution is in its Western Region and a "C" if in its Central Region. Doug recognizes that NAIC codes are not a solution that works for all health plans, and that Highmark may need to change its requirements if and when a national plan ID is established. Likewise, according to Tim Collins, Kentucky Medicaid now has plans to re-assign proprietary provider IDs in anticipation of HIPAA . These IDs are "intelligent," in that the 10-digit number used on the ISA denotes the type of submitter (e.g., Medical Practice, Software Vendor or Billing agent), further qualified by the type of institution on whose behalf the transaction is being submitted (e.g., Hospital, clinic, pharmacy, dental, etc.). Doug Renshaw didn't go into detail on how Highmark's provider IDs are generated, or whether they are "intelligent" or not. I guess that doesn't matter. What I do know now from these few "scenarios" - including the Medicaid sample from John Bristor - is that payers sure do like proprietary provider IDs! But do providers feel the same way? William J. Kammerer Novannet, LLC. +1 (614) 487-0320
