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Medical Coding News Archives

Health Plan Identification Numbers Finally to Be Implemented

August 1, 2014:

Regina Magnani, RHIT, Clinical/Technical Editor

Health plans, except for small health plans, have until November 5, 2014, to obtain their health plan identification number, or HPID. Small health plans should obtain their HPID by November 7, 2015, and health plans, covered health care providers, and health care clearinghouses must fully implement the use of the HPID by November 7, 2016.

The idea of a standardized identification number to be used by all parties to represent a specific health plan was first discussed in the Health Insurance Portability and Accountability Act (HIPAA) enacted into law in August of 1996. The Affordable Care Act took up the idea of an HPID, describing it as a “cut in red tape” that would “save up to $6 billion over 10 years.”

The Department of Health and Human Services has allowed health plans to use a wide range of identifiers that do not have a standard format. As a result, health care providers report running into time-consuming problems, such as misrouted or rejected transactions due to insurance identification errors. The HPID and its associated other entity identifier (OEID) are intended to address this issue.

The OEID is a voluntary identifier for parties NOT:

  • Eligible to obtain an NPI
  • Eligible to obtain an HPID
  • An individual

The final rule for the national provider identifier (NPI) was published on September 5, 2012.

Title 45, section 160.103, of the Code of Federal Regulations defines a health plan as “an individual or group plan that provides, or pays the cost of, medical care (as defined in section 2791(a)(2) of the PHS Act, 42 U.S.C. 300gg-91(a)(2)).” The term “health plan” includes, but is not limited to, the following:

  • A group health plan
  • A health insurance issuer
  • An HMO
  • Part A, Part B, Part C (Medicare Advantage), and Part D (Prescription Drug Benefit) of the Medicare (Title XVIII) program
  • Medicaid (Title XIX) program
  • Medicare supplemental policy
  • The health care program for uniformed services under Title 10
  • The veterans’ health care program under 38 U.S.C. chapter 17
  • Indian Health Service program under the Indian Health Care Improvement Act
  • Federal Employees Health Benefits Program
  • Any other individual or group plan, or combination of individual or group plans, that provides or pays for the cost of medical care

Title 42, section 300gg-91(a)(2), of the Code of Federal Regulations defines medical care as: (A) The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body (B) Amounts paid for transportation primarily for and essential to medical care referred to in subparagraph (A) (C) Amounts paid for insurance covering medical care referred to in subparagraphs (A) and (B).

Health plans are further divided into a controlling health plan (CHP) and a subhealth plan (SHP). CHPs must obtain an HPID for itself. A CHP may obtain an HPID for its subhealth plans or may direct them to obtain their own HPID. An SHP is not required to obtain an HPID but may do so.

Applications for HPID and OEID are available through Accessing Health Plan and Other Entity Enumeration System (HPOES). HPOES is available at the CMS Enterprise Portal here.


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