Not to muddy the waters any more but Trigon BC/BS and Anthem BC/BS announced today they are merging. It will be interesting to see if they completely merge (one payer ID) or are maintained as 2 separate entities (unlikely). There might be issues like payer ID and or Plan ID cutover dates. It will be interesting to watch because there are other mergers in discussions.
Regards, David Frenkel Business Development GEFEG USA Global Leader in Ecommerce Tools www.gefeg.com 425-260-5030 -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Monday, April 29, 2002 2:23 PM To: WEDi/SNIP ID & Routing Subject: Re: Fourth National HIPAA Summit: session on Identifiers, EDIAddressing and Routing 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
