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HIPAA Electronic Transaction Standards

And Health Plan Identifier (HPID)

The Affordable Care Act (ACA) and the Health Insurance Portability & Accountability Act (HIPAA) require new standards for electronic health plan transactions, including eligibility, claim status, and payment. These provisions apply to group health plans, including medical, dental, vision, and some health reimbursement arrangements (HRAs). HRAs that cover deductibles only or out-of-pocket costs do not require HPIDs as these are more like additional plan benefits than stand-alone plans. Flexible spending accounts (FSAs) and health savings accounts (HSA) are individual accounts directed by the consumer to pay health care costs and as such, are not required to obtain an HPID.

Health plans will need to obtain a Health Plan Identifier (HPID) to be used in electronic transactions. The HPID is a 10-digit code intended to streamline transactions between carriers, administrators, providers, and financial institutions. Self-funded employers and health plans are required to obtain their own HPID. Fully insured plans do not need to secure an HPID as the carrier or insurer will have the HPID. Small health plans with less than 50 participants are generally not subject to the HPID requirement.

Applications for HPID are available through HHS’ Health Plan and Other Entity Enumeration System (HPOES). HPOES is housed within the Health Insurance Oversight System (HIOS) of the Centers for Medicare & Medicaid Services (CMS). Videos are available to help employers learn more about the application process, including step-by-step instructions.

Key compliance dates:

HPID must be used in health plan electronic transactions beginning November 7, 2016.

Detailed information and instructional videos are available on the CMS website: http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/Health-Plan-Identifier.html

The AE Trust will be obtaining the HPID for its health and dental plans. Employers with Health Reimbursement Accounts (HRAs) may be required to obtain an HPID for those plans if they reimburse for more than cost-sharing amounts for covered services under a health plan. For employers utilizing a vendor to administer their company HRA, the vendor should be able to assist and answer questions regarding whether an HPID is needed for the plan.

Source: Department of Health and Human Services