Ronald:
If we had any "discussion about how information is processed prior to
the lookup," it was solely in the context of the provider obtaining the
ID of the plan or payer (somehow - perhaps from the insurance card), or
the payer using the usually present Tax ID of the provider. We have to
make the assumption that some ID is available (to either provider or
payer, or their agents) for performing the initial lookup.
Once you have an ID, it should be clear sailing from there, even though
multi-stage lookups might have to be performed: e.g., if the provider
has the (future) National Plan ID in hand, he can look up the (1)
Electronic Partner Profile (CPP) for the plan, which in turn might be
nothing but a reference to the (2) Third Party Administrator or
insurer's CPP, and finally, the TPA's CPP might reference its (3)
Clearinghouse's CPP for the detailed Delivery Channel ("EDI Address")
attributes which define the actual transport method and port address.
I hope we don't have to understand, in detail, the "major models of
insurance" to describe a workable Registry and CPP system - except in
order to illustrate examples of how the thing works, as I just did above
(a model based on a self-insured plan handled by a TPA using a
Clearinghouse). In that example, we used the Plan ID to arrive at the
EDI portal at a CH to send claims or eligibility inquiries. The Plan ID
would still presumably appear in the application transaction set,
otherwise the TPA - which handles dozens or hundreds of self-insured
plans - would not know for whom the claim was intended.
Solving the problem of how to obtain the National Plan ID (or in today's
world, the payer and proprietary plan IDs) is out of scope for our
project. But it is a real problem, which Chris Feahr confirms. As I
indicated in my previous e-mail, it seems to have been solved adequately
in the Pharmacy world according to David Feinberg.
William J. Kammerer
Novannet, LLC.
+1 (614) 487-0320
----- Original Message -----
From: "Ronald Bowron" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Cc: <[EMAIL PROTECTED]>
Sent: Monday, 29 April, 2002 02:52 PM
Subject: Re: Fourth National HIPAA Summit: session on Identifiers,
EDIAddressing and Routing
William,
If you recall, there was discussion about how information is processed
prior to the lookup. To solve the routing issues, must we first
understand the process that occurs before routing can begin? Should we
identify and validate our assumptions about the pre-routing process? It
seems the information gathering process that occurs before a transaction
set can be submitted via an exchange header will significantly impact
the type of information needed in a directory or CPP.
Do we need to understand the difference between the major models of
insurance - i.e. Employer Sponsored(HMO, PPO), Self-Insured,
Medicare/Medicaid, etc. and what type of information is necessary to
properly identify the Plan that covers the patient?
Do we get input from the provider side as to the typical processes used
to gather insurance information? What types of information can you
typically rely on from the patient to identify the appropriate Plan?
How do you get that plan information today? Which types of plans are
the most difficult to collect information about?
What percentage of the 30% non-card carrying patients do the providers
simply "Patient bill", and then let the patient deal with the insurance
company?
Would this be within scope of our initiatives?
So many questions, so little time....
-Ronald Bowron
