WEDI’s HPID Workgroup Announces Release of Issue Brief: “What is the Difference Between a Health Plan and Payer?”

Issue Brief from WEDI’s HPID Workgroup simplifies definitions and usage of terms according to the HPID Final Rule.

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The lack of clarity around the definition of a health plan and payer has caused significant challenges among the payer community in the development of their enumeration strategy. It is our hope that these definitions help provide a common understanding.

Reston, VA (PRWEB) July 28, 2014

The Workgroup for Electronic Data Interchange (WEDI), the nation’s leading nonprofit authority on the use of health IT to create efficiencies in healthcare information exchange, announced today its Health Plan Identifier (HPID) Workgroup has developed an issue brief titled, “What is the Difference Between a Health Plan and Payer?” The HPID Workgroup, a part of WEDI’s Strategic National HPID Implementation Process, worked closely with the Centers for Medicare and Medicaid Services (CMS) to identify common misuse of the terms “health plan” and “payer” across the industry.

These terms, often used interchangeably in the regulation, can cause a misconception of an organization’s role. In an effort to help the industry understand the differences in these terms and how to best use them, WEDI partnered with ASC X12 to develop this issue brief, which includes definitions of both terms and clarifies the role each plays in standard transactions according to the HPID Final Rule.

The brief further explains these defined terms as they are affected by the HPID Final Rule compliance date. An organization currently identified as a payer will continue to be identified as such. However, one that is currently identified as a health plan – and continues to be identified as a health plan after November 7, 2016 – must use an HPID.

“The lack of clarity around the definition of a health plan and payer has caused significant challenges among the payer community in the development of their enumeration strategy,” said Devin Jopp, Ed.D, WEDI president and CEO. “It is our hope that these definitions will help provide a common understanding of how to apply these terms across our industry.”

The issue brief is available for review and can be found online here.

About WEDI
The Workgroup for Electronic Data Interchange (WEDI) is the leading authority on the use of health IT to improve healthcare information exchange in order to enhance the quality of care, improve efficiency, and reduce costs of our nation’s healthcare system. WEDI was formed in 1991 by the Secretary of Health and Human Services (HHS) and was designated in the 1996 HIPAA legislation as an advisor to HHS. WEDI’s membership includes a broad coalition of organizations, including: hospitals, providers, health plans, vendors, government agencies, consumers, not-for-profit organizations, and standards development organizations. To learn more, visit http://www.wedi.org and connect with us on Twitter and LinkedIn.


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  • Dave Anderson
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