HPID Part I: What Is It?

This is a bit out of order, but this first part of HPID was originally sent out as an email as a part of the Thought Leadership Series on HPID.  We thought it might be helpful to have all of it centrally located on the blog.  Enjoy!

The Thought Leadership Series on HPID by Victor Laguardia


In September 5, 2012, the Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced a final rule that will save time and money for physicians and other health care providers by establishing a unique health plan identifier (HPID). The Health Plan Identifier (HPID) is used to standardize how health plans are identified in transactions to avoid misrouting of transactions and incorrect rejections. Beginning November 7, 2016, health care providers will be required to use an HPID to identify a health plan in standard transactions like claims or eligibility requests.

The final rule introduces a mandatory enumerator for payers, the Other Entity Identifier (OEID), a new process to obtain the HPID and OEID on the Health Plan and Other Entity Enumeration System (HPOES) that is housed within CMS’s Health Insurance Oversight System (HIOS). This system will be used to obtain a HPID or OEID, where there are two different HPID application types, the Controlling Health Plan and Sub health Plan, both with different requirements.

Entity Type Compliance Date for Obtaining HPID  Full Implementation Date for Using HPID in Standard Transactions
Health Plans, excluding Small Health Plans Nov 5, 2014 Nov 7, 2016
Small Health Plans* Nov 5, 2015 Nov 7, 2016
Covered Healthcare Providers N/A Nov 7, 2016
Healthcare Clearinghouses N/A Nov 7, 2016

*Small Health plan is defined by a health plan with annual receipts of $5 million or less.

Concern and Confusion

There is great concern in the industry that by introducing a new, not equivalently mapped, enumeration into the transactions may reintroduce past issues that have been solved, which impacts provider accounts receivable and re-introduces significant privacy and security risks. The Industry wants to understand the perceived ROI. There is broad variation in interpretation in what must be enumerated. This is in part based on the definition of a health plan, the Controlling Health Plan definition and/or the self-insured group health plans inclusion in the HPID Final Rule.

Trading partners of health plans are increasingly concerned that greater enumeration will result in a disruption of the current, well-functioning transaction flows, potentially resulting in payment disruptions and accounts receivable impacts as well as privacy and security breaches due to misrouted transactions. Since the X12 implementation guides will require a new Addenda version, all translator software and editors will have to be updated or all transactions will fail HIPAA edits. With the new notes in the transactions to support HPID, it will also create new rules for translators and HIPAA editors.

Both WEDI and the American Medical Association had presented CMS with recommendations to solve the new rule confusion and the concerns from the industry. On our next communication we will focus on these recommendations.


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