News & Updates
Under the Affordable Care Act (ACA), health plans that meet the definition of a controlling health plan must obtain a health plan identifier, or “HPID.”
A controlling health plan:
Health Plans with an HRA
Health reimbursement accounts (HRA) with 50 or more participants are considered self-funded health plans (ASO) under HIPAA, as they are funded by the employer. As a result, an HRA paired with a fully insured health plan likely is a controlling health plan, and the customer will need to obtain a health plan identifier for the HRA. Fully insured customers are not required to obtain health plan identifiers for their standalone fully insured medical plans.
HRAs paired with ASO health plan would likely be a sub-health plan. A sub-health plan is not required to obtain a health plan identifier, unless it chooses to obtain one.
Health plans that meet the definition of a controlling health plan are required to have a health plan identifier by November 5, 2014, but small health plans have until November 5, 2015. According to the Centers for Medicare and Medicaid (CMS), plans with less than $5 million in annual receipts are small health plans.
About the Health Plan Identifier
The health plan identifier requirement falls under the Administrative Simplification provision of the ACA.
In 1996, the Health Insurance Portability and Accountability Act (HIPAA) introduced the health plan identifier. The health plan identifier creates a standard data element for health plans. The intent of the health plan identifier is to simplify the routing, review and payment of electronic transactions, and reduce errors and manual intervention.
The final rule, published September 5, 2012, adopted a 10-digit health plan identifier for health plans to use in electronic HIPAA transactions. HIPAA transactions include:
Using the Health Plan Identifier
After November 7, 2016, UnitedHealthcare will be required to use an ASO plan’s health plan identifier in a HIPAA-covered transaction, such as an electronic claims remittance advice, but only if UnitedHealthcare identifies the plan in the transaction. If UnitedHealthcare does not identify the ASO plan as the payer or source in HIPAA transactions, but instead identifies a UnitedHealthcare entity that acts as a third-party administrator (as is permitted under HIPAA standards), then UnitedHealthcare is not required to use the plan’s health plan identifier.
Applying for a Health Plan Identifier
The online application is available through the CMS Health Plan and Other Entity Enumeration System (HPOES). HPOES is housed in CMS’ Health Insurance Oversight System and must be accessed via the CMS Enterprise Website. HPOES first-time users must register themselves and their organizations, and then select the type of health plan identifier application (controlling health plan, sub-health plan or other identifier).
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