November 2007 Newsletter
I Have A Plan…
A Health Plan ID, that is
One of the most misunderstood fields on the UB-04 is Block 51 – HEALTH PLAN ID. This field is defined in the NUBC manual as the number used by the health plan to identify itself. At this point in time, that number can be in almost any format. It is currently self-created by each payer and distributed as a proprietary number to be reported to that specific payer. Some payers even designate what they want to see as the Health Plan ID for other payers in the industry. Thus, the same payer may have different IDs depending on where the claim is being submitted.
Like payers are not even consistent. For example, Blue Cross plans generally want their specific BC plan code (i.e. Anthem BC, OH – 332, Highmark BC, WV – 444) in this field, but not always. Some Blue plans want two leading zeroes while others may only want the base 3-digit plan codes. Because of this, it is very difficult for providers to know what to put in this block on the form. Fortunately, companies like Emdeon have made this somewhat easier by using the NAIC assigned 5-digit codes assigned to the commercial payers that they process. They may also assign their own 5-character codes, however, to U.S. Department of Health & Human Service payers and payers that seem to be in flux during their implementation cycles. A payer may be available through Emdeon and through THIN (The Health Information Network), but may have completely different Health Plan IDs. Are you confused yet?
To try to address the myriad of codes being used for all of these payers, Quadax, Inc. has, for the most part, always put the payer code in ourselves in the ANSI segments/loops so that it will go out properly to the payer being billed. This may be the Emdeon Payer ID that is matched to each of the commercial payer names, or it may simply be the code in the payer’s companion guide that they want to see used on the ANSI loop for their incoming information. This has worked in the industry for years, but is becoming an issue as of late due to other lines of business that a payer may now process (i.e. Medicare HMOs, Medicaid HMOs, etc.). When these new lines of business are being sent to an entity, such as a Blue Cross or commercial payer, they may want a different Health Plan ID for that specific line of business. This can make it very difficult for Quadax, Inc. to determine the correct value. Therefore, we are systematically making Block 51
Our first step was to continue sending the previously defined code for most of the payers being billed, unless we have worked it out with a specific payer and our clients as to what is a valid code. We then allow the client to control this field. Second, we have changed our processing to pass the Health Plan ID directly from Block 51 into the ANSI payer loops/segments for the other payers on the claim (payers not being directly billed electronically). This gives the client full control of the Health Plan ID field for each of the other payers being reported.
The government has been discussing for years (but has not finalized) a National Plan Identifier that will eventually be assigned to all payers and will be controlled by one entity, similar to the NPI currently being used for Providers. Rumors are that it may even be in a similar format as the NPI. After consistent Health Plan IDs have been assigned to all payers and their specific lines of business (if needed), Quadax, Inc. will be in a good position to simply add the appropriate editing for Block 51 for all payers being billed on the claim. We will then simply pass all of the values being entered directly into the ANSI formats. For more information regarding the Health Plan ID, please refer to the current NUBC manual for the UB-04 claim form.