All official NCVHS documents including meeting transcripts are posted on the NCVHS Website ( See transcript and PowerPoint presentations for further information.

Department of Health and Human Services


Subcommittee on Standards

July 19-21, 2010

Administration Simplification under the Patient Protection and Affordable Care Act
National Health Plan Identifier and Operating Rules for Eligibility and Claims Status

Hamilton Crowne Plaza Almas Building – Oasis Room
1315 K Street, NW, Washington, D.C. 20005

Executive Summary

The National Committee on Vital and Health Statistics Subcommittee on Standards was convened on July 19 – 21, 2010 in Washington, D.C. The meeting was open to the public and broadcast live on the Internet. A link to the live broadcast is available on the NCVHS homepage.


Committee Members

  • Walter G. Suarez, M.D., M.P.H., Co-Chair
  • Judith Warren, Ph.D., R.N., Co-Chair
  • Justine M. Carr, M.D.
  • Larry A. Green, M.D. (by phone 8/19 & 8/21)
  • John Houston, J.D.
  • J. Marc Overhage, M.D., Ph.D.
  • William J. Scanlon, Ph.D.


Staff and Liaisons

  • Margret Amatayakul, Consultant
  • Jeannine Mtui, Affirma Solutions
  • Lorraine T. Doo, M.P.H., CMS
  • Jorge A. Ferrer, M.D., M.B.A. (by phone)
  • J. Michael Fitzmaurice, Ph.D., AHRQ
  • Marjorie Greenberg, NCHS/CDC, Executive Secretary
  • Debbie Jackson, NCHS
  • Katherine Jones, NCHS
  • Donna Pickett, NCHS/CDC
  • Jim Sorace, M.D., ASPE
  • Marietta Squire, NCHS
  • Karen Trudel, CMS
  • Michelle Williamson, NCHS


July 19, 2010

  • Robert Ahlstrom, ADA (written)
  • George Arges, AHA
  • Tammy Banks, AMA
  • Peter Barry, Enumeron
  • Don Bechtel, WEDI
  • Ellen Cannon, WV Dept. of HHS
  • Jim Daley, BCBSA, AHIP
  • Laurie Darst, Mayo Clinic
  • Larrie W. Dawkins, MGMA, Wake Forest
  • Jerry Diffley, QuestDiagnostics/ACLA
  • Gregory M. Fisher, United Health Group
  • Sheila Frank, Public Health Consortium
  • Annette Gabel, Medco
  • Lynne Gilbertson, NCPDP
  • Cathy Graeff, Sonora Group
  • John Kelly, Harvard Pilgrim HealthCare
  • Gail Kocher, WEDI
  • Barbara Mayerick, VA (Provider)
  • Tim McMullen, Cooperative Exchange
  • Randy Miller, NMEH (by phone)
  • Dan Powell, VA (Plan Side)
  • Susanne Powell, Emdeon
  • Lori Robinson, CMS MA Plans
  • John Quinn, HL7
  • Margaret Weiker, X12
  • Jim Whicker, AAHAM

July 20 and 21, 2010

  • Bill Alfano, BCBSA
  • George Arges, DSMO/NUBC
  • Tammy S. Banks, AMA
  • Don Bechtel, WEDI
  • Pete Cutler, Washington State Insurance Dept.
  • Michelle V. Davidson, Walgreens
  • Richard Donoghue, NYU Langone Medical Center
  • Jan Estep, NACHA
  • Lynne Gilbertson, NCPDP
  • Janet Jackson, BCBSNC
  • Jerry Killough, Clinix, HBMA
  • Patrice Kuppe, State of Minnesota
  • George Langdon, GE HealthCare
  • Gwen Lohse, CAQH CORE
  • Barbara Mayerick, VA (Provider)
  • Jim McNiff, Montefiore (by phone)
  • Joseph Miller, HIMSS
  • Randy Miller, NMEH (by phone)
  • Nancy Orvis, DoD
  • Dan Powell, VA (Plan Side)
  • Susanne Powell, Emdeon
  • Nancy Spector, NUCC
  • Jeanette Thornton, AHIP
  • Eric Wallace, Linxus
  • Margaret Weiker, X12

Others Present:

  • Ellen Ambrosini, CMS
  • Liza Assatourians, AMA
  • Connie Baher, VA
  • Bob Bailey, Fifth Third Bank
  • Jeannette Thornton Barrett, AHIP
  • Martha M. Beard, J.P. Morgan
  • Robert B. Burleigh, Brandywine Healthcare Services
  • Helen Campbell, United Health Group
  • Paul M. Campbell, Manatt Health Solutions
  • Dale A. Chamberlain, Gateway Pharmacy Consulting
  • Rich Cullen, BCBSA
  • Suzanne Duda, Consultant
  • Janet O. Estep, NACHA
  • Bill Finerfrock, Capitol Associates, Inc.
  • Joscelyn Funnie, CMS/OESS
  • Steven Every, CMS
  • Rachel Foerster, Consultant
  • Jonathan French, HIMSS
  • JoAnne Glisson, ACLA
  • Stuart Hanson, Fifth Third Bank
  • Theresa M. Holly, PriceWaterhouseCoopers
  • Angela L. Jeansonne, AOA
  • Pamela Jodock, Wellpoint
  • Tim Kaja, UHC
  • Ian Macoy, NACHA
  • Jack Joseph, PriceWaterhouseCoopers
  • John S. Klimek, NCPDP
  • Frank A. Kyle, ADA
  • Steven S. Lazarus, BIG
  • Delena Marine, DHHS/CMS
  • Ken McCaslin, Quest Diagnostics
  • Dirk C. McMahon, UHC
  • Laura R. Megas, Cognosante
  • Debbi Meisner, Emdeon
  • Anna Orlova, PHDSC
  • Ruth-Ann Phelps, VA
  • John E. Quinn, Health Level Seven Intl.
  • Erin Richter, CAQH
  • Dan Rode, AHIMA
  • Debbie Routt, CAQH
  • Bernadette, Ryan, VIPS/GDIT
  • Mary J. Ryan, Medco
  • Mari Savickis, AMA
  • Donna Schmidt, CMS
  • James A. Schuping, WEDI
  • Cathy Sheppard, X12
  • Amanda Sibley, VIPS
  • Lee Ann Stember, NCPDP
  • Robert M. Tennant, MGMA
  • Robin J. Thomashauer, CAQH
  • Peter Walker, Aetna
  • Kristine Weinberger, ACS
  • Miranda Woolston, CAQH


All official NCVHS documents are posted on the NCVHS website


  • Subcommittee members were asked to send additional use cases and comments on operating rules to Lorraine Doo, M.P.H.
  • Subcommittee members were asked to present examples of barriers or challenges and concerns about the timing of the operating rules deadline, which comes after the 5010 implementation (for inclusion into the Subcommittee’s letter to the full Committee in September 2010).

Monday, July 19, 2009


Walter G. Suarez, M.D., M.P.H., Co-Chair; Karen Trudel, CMS

Panel A1 Proposals for a National Health Plan Identifier

  • Proposal from Health Plans Jim Daley, BCBSA, AHIP
  • Proposal from Providers Tammy Banks, AMA
  • Proposal from WEDI Don Bechtel, WEDI
  • Proposal from Pharmacy Industry Lynne Gilbertson, NCPDP
  • Independent Proposal Peter Barry, Enumeron

Panel A2 Reactions and Perspective

  • Cathy Graeff Sonora Group
  • Lori Robinson CMS MA Plans
  • Margaret Weiker X12
  • Randy Miller NMEH
  • Greg Fisher United Health Group
  • John Kelly Harvard Pilgrim
  • Dan Powell VA
  • Barbara Mayerick VA
  • Annette Gabel Medco
  • Larrie Dawkins MGMA
  • Jim Whicker AAHAM
  • Laurie Darst Mayo Clinic
  • George Arges AHA
  • Jeffrey Diffley Quest Diagnostics
  • Ellen Cannon NASMD
  • Suzanne Powell Emdeon
  • John Quinn HL7
  • Tim McMullen Cooperative Exchange
  • Gail Kocher WEDI
  • Sheila Frank Public Health Consortium
  • Robert Ahlstrom ADA (written)

Tuesday, July 20, 2010


Judith Warren, Ph.D., R.N., Co-Chair; Walter G. Suarez, M.D., M.P.H., Co-Chair; Lorraine T. Doo, M.P.H., CMS

Panel B1 Author Presentations of Operating Rules and Standards

  • Gwen Lohse CAQH CORE
  • Richard Donoghue NYU Langone Medical Center
  • Eric Wallace Linxus
  • Lynne Gilbertson NCPDP
  • Margaret Weiker X12

Panel B2 Reactions and Perspective

  • Patrice Kuppe State of Minnesota
  • Pete Cutler Washington State Insurance Dept.
  • Jeanette Thornton AHIP
  • Jan Estep NACHA
  • Tim McMillan Cooperative Exchange
  • Jim McNiff Montefiore (by phone)
  • George Arges DSMO/NUBC
  • George Langdon GE HealthCare
  • Jerry Killough Clinix, HBMA
  • Barbara Mayerick VA
  • Dan Powell VA
  • Nancy Orvis DoD
  • Nancy Spector NUCC
  • Tammy Banks AMA
  • Michele Davidson Walgreens
  • Janet Jackson BCBSNC
  • Randy Miller NMEH
  • Susanne Powell Emdeon
  • Don Bechtel WEDI
  • Joe Miller AmeriHealth Mercy

Wednesday, July 21, 2010

Subcommittee Discussion

The focus of the discussion was on the health plan identifier, using a list of terms developed by four meeting participants as the starting point (slideshow format). Once taxonomy has been achieved, use cases (i.e., how to use the agreed-upon terms) can be developed. Questions included: what is the actual standard? Who is eligible? What kind of entities qualify to become enumerated? What level of enumeration is recommended for standardization? What other levels are optional or available? Other issues mentioned were the enumeration process; information within a central repository; pharmacy and applicability; Medicare and Medicaid considerations about the number; and dual use during the transition (i.e., the potential to use both the number and health ID cards). It was noted that different terms may be interpreted differently among different segments, hence the creation of general categories rather than specific titles (refer to Identifying the Basic Terms and the Types of Information They Represent document). In addition to clarifying specific terms, suggestions were made to further refine this document in such areas as: processes for pharmacy versus workers compensation claims versus medical claims; the hierarchical relationship between chart boxes; placement of payment programs (in the benefits area), source of payment typology (e.g., Medicare) under entity, vendors and clearinghouses; and who the entities are, paying attention to possible confusion between the entity and the benefit design.

Questions arose about the distinction between entity versus product distinction. The product, benefit structure and population eligible for the product must be defined. Product type is important. The “ultimate” public policy question is, “what is the source of payment?” (as well as, “who is responsible for payment?”). Product definition will identify the source of payment. Further payment questions were raised (e.g., who is paying; what are they paying for and for whom; and what is the relationship between payer and provider). Information about such things as deductibles and co-pays can be derived from a single number point to the exact right place. What must be determined is the minimum amount of information a provider needs and the best way to obtain it when working directly with patients. There was further discussion about requirements and relationships (i.e., what can the X12 transaction actually hold?) and what can be done in the real world. The term “rental contracts” was clarified and operating rules (relative to 271 and 270) were raised. Patients need to know if they are in or out of a network.

Product definition is constantly changing in the market. A standardized way to recognize rental networks and product offerings across different organizations is needed. A hierarchical approach was questioned. Also discussed was the difference between information placed in the eligibility transaction versus later in a claim versus later in an 835. The relationship between payer and provider must be represented but at present, only the payer and beneficiary are reflected.

The Subcommittee’s work is to decide types of categories for which numbers will be issued. The purpose is to simplify and make processing eligibility, claim submissions and payments more efficient from the beginning of treatment. The process should identify the patient, payer and benefits eligible to be covered as well as crunch dates and what providers can expect. Also to be identified are the current state; gaps; what is broken; tools; and a clear sense of what must be achieved. Questions asked were: is the patient in the right place? What is the transaction route? How is a claim differentiated from an eligibility query? How much will the provider get paid? What will the patient owe? How will benefits be coordinated with a secondary payer? Because there is currently no standard identifier for where a transaction goes, the number must be standardized. In addition, providers need adequate information about eligibility transactions to convey to patients. Also discussed was “ex-post analysis,” a process that aggregates information to increase understanding of whether contracts are being fulfilled (e.g., Medicare Advantage Program). Will the enumeration process allow for data aggregation that helps to answer basic policy questions?

The standard does not define entity or rental network. The information source definition identifies eligibility or benefit information. The plan administrator (primarily insurance companies) is defined as whoever is responsible for the plan (usually referred to as “payer”). Further discussion about these issues within the context of 5010 ensued. Relative to the Guides, a suggestion was made to fast-track 5020 or to provide emergency errata, if the rules are going to change. A national ID card will help providers know what to do when three or four options for information source are presented.

Dr. Overhage presented a use case, using his physician practice office as the example and noting a difference in use within large and small group settings (see transcript for specifics). Ms. Banks (AMA) emphasized the complexity of the process and the importance of one identifier, noting that the provider network contract has nothing to do with the benefit plan. A registry is also needed to do an auto-population of what the ID number means. More information may be needed than the entity (e.g., product function). Beneficiary networks were differentiated from contracting networks. It was noted that different pieces of information are dealt with at different points in time (e.g., eligibility is different from claims). A predictive information flow is needed (such that what occurs in eligibility is a good predictor for claims submission later on). The hope is that the unexpected can be minimized by having better information upfront. The value of a database or database as registry versus an ability to more directly access detailed care information from a health plan was also discussed. Ms. Banks described Type I (PPO/patient-specific benefit) and Type II (NHPI/ entity or organization) within the AMA system. One must distinguish between identifying and enumerating a health plan from the need to provide information about the relationship of patients to their health plans. At present, the standards put in place through HIPAA are not fully used. Products for primary care physicians will become available with the development of tools.

Ms. Amatayakul presented a series of charts and with input, revised a specific use case chart entitled, “Use Case for NHPI: Current State Small Provider Specialist (PCPs rarely use because work is greater than return, except in MN where it is required): 270/271” intended to help Subcommittee members understand the current state of ID usage (see transcript and chart for specifics). Issues to consider include: is the NHPI needed and at what level? What are the benefits and burdens? Where does the 270 get sent? Does information accompanying the 270 come from a generic query or from more specific sources? Current ID is necessary but not sufficient (or standardized) to know where to send the 270 so the new health plan identifier is needed. Ms. Weiker noted that the 270 is sent to the envelope of the transaction (the identifier) rather than to the transaction itself, which differs from how the source in the actual transaction is identified (example given).

There was further conversation about what would happen if the national health plan ID were to be used for routing (e.g., add a qualifier). Eligibility questions differ from the questions about where to route transactions. A suggestion was made to put both routing identifier information and plan identifier information on a standard card and to identify who is responsible for managing the process (example given). Questions were raised about how to manage changes to new ID cards; and the need for a registry was reiterated. The topic of trading partner agreements was also raised. A clarification was made about the fact the product line is not necessarily known at the point of inquiry.

There was general agreement about the need for product line information on an employee card in response to a 270 request so that the physician knows the product, covered benefits and deductible. There was further discussion about the distinction between benefit plans and product lines as well as the interrelationships between different transactions. It would be valuable to consider the implications of a Plan ID with respect to Health ID cards. Information needed by providers and payers for generic and specific inquiries in and outside of benefit and rental networks was reviewed. The burden to payers who must provide a certain level of detail was discussed as were opportunities such as cutting down on phone calls between patients, providers and health plans.

The complexities of reimbursement and billing were reviewed. Could a national health plan identifier allow for a standardized link between a number and a specific patient fee schedule? Would fee information be available in the registry? Who enumerates a contract number qualifier? What physicians need (and when) in order to obtain product information and a fee schedule was discussed at length. The physician’s fee schedule was differentiated from the service plan fee schedule. Examples were presented to clarify enumeration, whether at a company or product level. The need for consistent coordination of benefits across health plans was mentioned as was the impact of approved trading partner relationships.

The intricacies of electronic transactions and the enrollment process were raised. When a member with more than one type of insurance enrolls in a health plan, the enrollment must indicate the national health plan identifier, which becomes part of the system. The information is gathered on the 270/271. As the 834 is not a required transaction on HIPAA for employers, the request for information would have to be revamped from every type of enrollment. Relative to payment requests and routing, it was noted that the entity administering the 270 is not necessarily the entity that administers the claim and all these entities need numbers.

Operating Rules

A suggestion was made for the Subcommittee to consider the timing of the operating rules deadline, which comes after the 5010 implementation. Presentations by Gwen Lohse (CAQH CORE) and Lynne Gilbertson (NCPDP) provided examples of operating rules (refer to transcript and PowerPoint presentations for specifics). The Subcommittee then reviewed legislative criteria and NCVHS’s criteria for examining HIPAA standards relative to operating rules. The five criteria in the legislation identified the need for an entity. Also noted were three requirements for NCVHS to review operating rules. With the advent of HIPAA, NCVHS has used a set of guiding principles.

Three state groups (Linxus, Minnesota and Washington) provided a response to the two proposals for the operating rules entity. Ms. Kuppe from Minnesota thought the timing issue should be considered but believes that it is acceptable to separate pharmacy from the X12 transactions and the two different operating rules developers. Standards are instrumental in formatting the data. Operating rules with clear data and grouping of code sets eliminate the need for a companion guide. Generic rules about connectivity are needed. Eligibility or claims requires their own rule book. Ms. Lohse noted that many think that the infrastructure and data content are both necessary for the intent of the legislation.

Eric Wallace (Linxus) stated that the core problem to solve has to do with getting the business value of the transaction. The standards have the potential to incorporate the business value. For the long-term, which is critical, a group representing the business imperative is necessary, equally directed by plans and providers. The DSMO must be reconstituted to bring those parties together. Business priorities must be established by the industry. Transparency is needed in the establishment of regulations that identify operating goals so that standards organizations can develop them to meet the business need (examples given). The difference between operating rules and standards was noted although there was continuing confusion about their definitions. One open question is: does one have to go from 5010 to 6020 to get a standards update or is an operating rule needed? Mr. Wallace suggested an eligibility and claim status process that has everything going through one “hopper” through the SDOS. Then the SDOS should make recommendations about whether operating rules or standards are needed. It was suggested that the DSMO, which must be expanded to include certain organizations, should be the body that assigns the correct entity. The various state initiatives must be pulled together and prioritization of issues must be national. Due to an operating rules timeline, SDOS should be tested through the DSMO for the short-term with industry as a partner in order to define potential operating rules that help solve business problems.

Ms. Trudel clarified the intention of the statute (Section 1104 short-term; and Section 10109 long-term). As Section 1104 is not working, operating rules are needed for the standards that exist in order to get an ROI. Section 10109 establishes a longer-term process for reviewing and amending standards and operating rules. Long-term plans do not preclude short-term decisions. It was then noted that the cost of participation of one entity for every transaction standard would be prohibitive and difficult to manage. The definition of operating rule in Section 1104 was clarified. Ms. Weiker requested that specific DSMO change requests be submitted. Updating the guide is a collaborative process. SDOs are tested many times. It was noted that X12 supports NCPDP to be the single entity. The business benefit of 5010 was examined with an example given by Mr. Timothy Kaja of Untied Health Group. Implementation of 5010 was viewed as a failure that has increased consumer costs. A big challenge for organizations is how to remove administrative costs. Is the industry being set up to take costs out or add them in? A request was made for NCVHS to ask the operating rules organization to develop a use case that gets adopted in the industry. What criteria are needed for physicians and hospitals to use eligibility transactions? The operating rules organization can be the group that brings the next set of business criteria into the X12 transactions.

Dr. Warren adjourned the meeting at 3:00 p.m.

To the best of my knowledge, the foregoing summary of minutes is accurate and complete.


Judith Warren, Ph.D., R.N., Co-Chairman

Walter G. Suarez, M.D., M.P.H.,Co-Chairman