Rachel, Even though providers may participate in only as handful of health networks, they routinely see patients that are covered by hundreds of payers. THe exception could be some providers in very small rural communities, where there is one prevailing employer. Other than those, most providers will have in their systems a "payer database" of several hundreds of payers, with varying degree of activity. Anywhere from several claims per day to one claim per year. Then, the typical academic medical center has payer directories with several thousand entries in them. And, mergers, acquisitions, name changes, and coverage under new "service" names make things more difficult.
It is also common for payers and especially TPAs to operate under a multitude of names, based on the product or the sponsor of the health plan (employer) so it is hard to nail down. An average TPA will have around 50-100 health plans under its administration, most likely under different names. All under the same roof. And the name is not always a good indicator. I still remember when BCBS of OK bought an Aetna plan in Oklahoma and kept the Aetna name for some time even though it was actually part of BCBS of OK. Then you get the repricing organizations such as the PPOs in the mix. The claim transactions may look like they are for Plan X, but cannot be sent directly to Plan X. They have to be sent to the repricer first, and the repricer will, after repricing the claims, send them directly to Plan X. But the payments or eligibility transactions could be between the provider and Plan X directly. What a mess... Kepa Rachel Foerster wrote: > > William, > > I don't think it's unreasonable to believe that many large instituional > providers submit claims to dozens, if not more, payers. I suspect that only > smaller providers that may be in more rural rather than large urban centers, > might deal with only a few payers. > > Thus far the discussion here seems to be between William and me. I'd much > prefer to hear from the actual players in these various scenarios: > providers, payers and clearinghouse. > > Rachel > > -----Original Message----- > From: William J. Kammerer [mailto:[EMAIL PROTECTED]] > Sent: Saturday, January 19, 2002 12:51 PM > To: WEDi/SNIP ID & Routing > Subject: TCS: Payor identification codes for 837I > > An interesting question re: Identifiers posted to hipaalive yesterday > causes me to come up with some of my own: > > This request reminds me of the periodic queries for directories of SCAC > codes that arise on the general purpose EDI-L mailing list: I always > wonder why people just don't ask their (relatively few) carriers for the > respective codes. Likewise, wouldn't a provider (even an institutional > one) be dealing as a participating provider with relatively few payers, > and hence only need those payers' NAIC codes? - i.e., would there really > be a need for a NAIC directory? Does COB complicate the matter? - i.e., > the secondary payer may be known only by name, assuming it's provided by > the patient. Is the NAIC commonly used as the receiver (or sender) > field of the ISA? > > Rachel: corral me in if I'm making any unwarranted assumptions! > > William J. Kammerer > Novannet, LLC. > > ----- Original Message ----- > From: "Jeffrey Young" <[EMAIL PROTECTED]> > Sent: Friday, 18 January, 2002 11:12 AM > Subject: RE: TCS: Payor identification codes for 837I > > The National Association of Insurance Commissioners issues an identifier > to nationally significant carriers. Their database enumerates over > 6,000 indemnity and managed care life, accident and health care payers. > > -----Original Message----- > From: Marcus E. McCrory [mailto:[EMAIL PROTECTED]] > Sent: Friday, January 18, 2002 6:48 AM > To: HIPAAlive Discussion List > Subject: [hipaalive] TCS: Payor identification codes for 837I > > *** HIPAAlive! From Phoenix Health Systems/HIPAAdvisory.com *** > Regarding 2010BC-NM109 (page 127) & 2330B-NM109 (page 410) of the 837 > institutional guide, what currently serves as a central repository for > all of the payor identification codes for different plans/payors > throughout the country in the absence of a national identifier? Am I > missing a previously published list or well known resource? > > Thank you
