July 9, 1997 Public Forum: Unique Health Identifiers

07/09/1997

DR. MOORE: It is 1:30. We need to get moving. We have four more teams for presentations. This afternoon we will be doing the identifier team, followed by I believe the enrollment and transactions, personal enrolling, eligibility, et cetera. Then follow that by the coding, medical coding, and then followed up at the end will be the security team.

I have Mary Emerson, who is working on the national provider identifier, Fay Broseker on her left, who is working on the payer I.D. Karen, who is working on the implementation of the provider identifier, and the regs that -- Karen Trudell, excuse me, and Susan Abernathy from the CDC.

Susan is going to lead off this session, again talking about the identifiers for individuals. So, Susan?

DR. ABERNATHY: Our team was charged with recommending standard unique health identifiers. There were four identifiers to be named: the individual, which I'll talk about, the employer, health plan and health care provider that the others from the team will discuss.

Within the work of the individual identifier group, right now we are nearing the end of the process of analyzing the proposals that were given to us from the inventory that Bob Moore mentioned this morning, from the American National Standards Institute. They had done an inventory of all of the different proposals for all of these transactions, all the standards that existed, showing where the gaps were in the standards.

As we do that, we are using the criteria that were put together by the American Society for Testing and Materials, which is a standard that was developed by a standards development organization. If you will remember from this morning's presentations, this legislation has an emphasis in using standards that have been developed by a consensus process, as that one was.

They issued a guide for properties of a universal health care identifier. That guide has 30 criteria for identifiers in it. We have taken each of the proposals and gone through, applied those criteria to them and done an assessment of those.

We are also trying to stay in touch with the Social Security Administration, with their efforts to come up with some recommendations to Congress about the social security number. Their report to Congress is due -- I believe it is August 22, it is coming up soon. We also have been talking with the Postal Service about work they are doing that might have some connection to a health care identifier.

We wanted to give you an idea of what we have accomplished so far in the talks that we have had as a team and the evaluations we have done. We think that we are at the stage where we can begin to eliminate consideration of some of the items that were on the ANSE inventory. We think that we can eliminate considering the unenhanced, unverified social security number. We think that we can also eliminate the group of proposals that you would categorize as biometric. Those would be things like fingerprints, retinal scans, those kinds of readers of physical characteristics of the individual.

We also think that we can eliminate the proposal for an identifier based on an existing medical record number, plus the practitioner prefix.

The ones that we are still then considering as a team would be the enhanced social security number. We are looking at the proposal put forth by the Computer-Based Patient Record Institute that involves a check digit being added to the number, and a method of encrypting the number, and changes in the Social Security Administration itself to resolve some of the problems with the use of that number.

There are also several proposals based on personal immutable properties. Those would be things like date of birth, mother's maiden name, place of birth. There are several proposals that have combinations of those.

Then within that ASTM guide that we talked about, there is actually a proposal for an identifier that is used to show how you would apply the criteria, but we are actually looking at that identifier proposal as something for us to consider, too.

We are also looking at supporting technologies for an identifier, such as a master patient index system identified within the ANSE inventory as a directory service. We are also looking at different characteristics of public and private key encryption. That was also in the inventory.

Among the issues that we are having to consider as a team -- and I wanted to talk to you about the issues, because we are now at the most difficult point of implementation, where I think we have eliminated the easy things, and now we are really starting the struggle to come up with something that we would feel comfortable recommending.

Among those are the risks and limitations of the social security number as a health identifier, the fact that there are duplicate numbers out there, and that one person can get more than one number if they need to.

There is also the problem that in some of the proposals that we have been considering, there is a proposal for a number, but there is no discussion of an infrastructure would be needed to maintain that. So we are having to try to consider something that is a partial proposal, since it doesn't address those things.

We also are having to consider the adequacy of current technology for some of the ideas we have heard, like the master patient index and the public-private key encryption.

Then we are also very sensitive to the acceptance by the public of any kind of a national master patient index, or for that matter, even a national health identifier. We have about 20 people on our team, and we represent a large cross-section ourselves of citizens, and also we come from a number of federal agencies. So we have a wide range of opinions of our own, and interest in this identifier that we bring to the project that we have.

As we consider what our recommendation will be, one of the problems that we have to look at is how can we positively link that individual to the identifier. What is to say that one person has an identifier, someone else doesn't take that identifier and get health care in their name? We also are considering how could we come up with a method to prevent a duplicate identifier being issued to someone.

Then there is the issue of, are we really trying to help the process of computerized patient records by being able to link to previous records and come up with a longitudinal health care record for someone, or are we trying to be sure that we insure the right to anonymous care, if that is what the patient wants? So it is a struggle; those are almost opposing things that you are trying to do. So which side of that should our work fall on?

Then as we consider these, some of them seem like really good ideas. Yet, as we look at the cost to the American public, we can't really in good faith recommend that we try something like that on a national scale.

Then we have to look at the fact that there is probably -- because there is an opposing wish to be able to identify the person positively with another wish by some to not be able to, probably whatever we decide to recommend is going to meet with some controversy. So we are trying to be sensitive to that, too.

Before we go on to the next identifier, are there questions from the audience about the individual?

DR. TRACY: Sue, when will you publish your recommendation?

DR. ABERNATHY: That is a good question, when would we publish our recommendation. Our team actually is a little behind the other teams. We got started later. We first met as a team in March. We are trying to meet the same deadlines that were put up here earlier for the 18 months with standards, which would mean our first draft would have to be done very quickly.

Any other questions? Then I would like to introduce Mary Emerson.

DR. EMERSON: Hello. I am Mary Emerson. I am the other co-chair along with Susan Abernathy of the unique health identifiers implementation team. I am going to talk to you about the other three identifiers that our team has been considering. Those are the identifier for employers, the identifier for health plans and the identifier for health care providers.

I'm going to stop after each identifier so that you can ask questions on that particular one. But because our time may be limited, if you have a lot of questions, you may not be able to have us answer them all this afternoon, so I would like to give you my phone number and e-mail address, so if you have questions that aren't answered now, you can direct them to me later. My phone number is area code 410/786-7065, and the e-mail address is memerson @ hcfa.gov.

I will start out with the employer identifier. The current activities of the team are that we have been coordinating with the team that is developing the transactions that we think will use an employer identifier. These are enrollment and disenrollment in a health plan, first report of injury -- that would be used for workman's compensation -- and health care premium payments.

The current thinking of the team is that we would recommend the employer identification number that is issued by the Internal Revenue Service to be used in those transactions.

Three issues have been raised relating to the use of the EIN in these health transactions. The first is that the EIN isn't unique to the employer, that is, many employers have more than one EIN. So the question this brings up is, would this be a problem for health transactions. So far, our feedback is that it would not, and that the EIN that is used on the employee's W2 form would be the appropriate one to use in transactions relating to that employee.

The second issue raised is that some sole proprietors, that is, sole proprietors who have no employees, some of them do not have an EIN. The question this brings up then is, would they need to obtain an EIN to use in health transactions that they issue on their own behalf. Or alternatively, would they use their social security number in those transactions?

The answer to either of those questions probably brings up the third question I've got on the list here: would the use of the EIN in the health transactions require any sort of legislation or regulatory change.

With that, I would like to open the floor for questions that you may have on the employer identifier. But actually, in this case what I am hoping is that the employer identifier is not very controversial. Maybe you will even give me answers to my questions. But do you have questions on the employer identifier before we move on to the other identifiers? Please come to the mike.

DR. ZUBELDIA: One of the issues is that sole proprietors do not have an EIN. Would those very small entities be subject to HIPAA? If they don't even have an EIN, if it is a single individual, would they be required to do electronic transactions? Would we be required to deal with them under the law?

DR. EMERSON: I'm not sure of the answer to that. I think that we can say that if they want to submit electronic transactions, they would have to do it in the standard format.

Now, I know that the law is definite about providers, health plans and so forth using the standard transactions for electronic communication. But I don't think it directly addresses when employers have to use -- whether they have to use electronic transactions or not. I would think that it would not require them to use electronic transactions. Bob, would you like to address that?

DR. MOORE: In the enrollment and disenrollment and premium payment, we had expected that employers if they were going to use electronic transactions, would be using the standard transactions. The question of whether a sole proprietor, if he is an accountant or a lawyer and that is his whole business, would he be required? I don't know.

DR. EMERSON: Bob, I think your voice is not catching the mike there.

DR. MOORE: I'm sorry. If it just an individual who is in business as a sole proprietor, as I stated up there, I don't know how he would be required to do an EIN, just to sign up for health care with some plan. I would imagine he would be paying his premiums by check or some other way, like many of us do already. So in this case, he would do it on paper, I would think, which is not out of the ordinary for that level of volume and for those kinds of transactions. We were looking at mainly for -- it would be to enroll or disenroll in the plan where there might be some group.

Does anyone have an answer that they could help with that? The State Farm people here, do you have -- or any other insurer, Frank from the Blues? If I were a sole proprietor and I wanted to enroll with some group, and I am the only one, I would probably do it on paper.

Frank is with Blue Cross and Blue Shield Association.

DR. POKORNY: Yes, I am with Blue Cross and Blue Shield Association. In response to your question, I don't know if there is one answer. In most cases, if it is an individual, the sole proprietor would not be under a group contract. I think the purpose of the EIN would reflect group employment situations with several individuals that are covered under one contract. So I don't know if it applies here.

One wrinkle is if it is an affinity group, such as a professional association that could offer coverage to its groups members. That just came to me right now, and I would have to explore that one. I don't know what the answer would be.

DR. MOORE: How would that group be identified in submitting all the people that are enrolled in a plan? Or would all the people submit their enrollment in that particular plan individually, but using that affiliation?

DR. POKORNY: I don't know if there is one way in which that is done. I think both options are viable, but I don't know enough to really answer the question fully.

DR. MOORE: Okay. But it is one that we need to investigate a little more and explore further. Thanks.

DR. EMERSON: Thanks to both of you. I'll move on now to the identifier for health plans.

The team expects to propose that the payer I.D. that has been under development at the Health Care Financing Administration be proposed as the identifier for health plans. Payer I.D. is a nine-position numeric identifier. It includes one check digit. There is no intelligence in the number itself, and it has the capacity to enumerate 100 million health plans.

This would include the various entities that are listed as health plans in the law. It includes group health plans, federal programs like Medicare, VA, CHAMPAS and so forth, Medicaid programs, and we would also propose to give payer I.D.s to those employers that offer funded and unfunded health benefits, so that when they are acting in the role of a payer, they would use their payer I.D. in those transactions.

I want to contrast that to the employer I.D., where when an employer is acting in the role of a general employer, they would use the employer I.D. which we are suggesting, the EIN, in those transactions.

Just to go over a few of the payer I.D. system features, first of all, it is a registry of the business information about the entity that is enumerated, in this case the health plan. It is an electronic phone book of the entity names and their payer I.Ds, and it is a database of the information that is necessary to route electronic transactions such as claims electronically.

With that one issue that has remained controversial about the payer I.D., that is, the level at which enumeration should take place. Should it be at a high level, the level of the health plan, or should it be at a detailed level, where you might even be enumerating a policy under the plan, or something of that sort?

I would like to turn the mike over to Faye Broseker now. Faye is the regulation team leader for the payer I.D. effort, and Faye is going to entertain your questions about the payer I.D.

DR. BROSEKER: Hi. Are there any questions?

PARTICIPANT: You say the issue is high level versus detailed enumeration. I would be curious to know what the thinking is amongst the implementation team about which way to go, and if a direction has been considered, how would that affect the actual enumeration?

DR. BROSEKER: Currently right now, what we are proposing for the regulation process is that the health plan will act as the gateway to get the transaction to the front door, and then if they have any internal business addresses, then let them route it to the appropriate one. That is the current way we are going right now.

DR. ROBINSON: Hi, I have a couple of questions. The first one is, are carriers responsible for maintaining the registry, and if they are not, how do we keep it in sync with new parities that might be on incoming claims but not yet on the carrier's copy of the registry?

DR. BROSEKER: If the individual or the entity has a payer I.D., they themselves will be responsible for keeping all the data related to them current in the registry.

DR. ROBINSON: And when are the carriers then going to receive copies of the registry and their supplemental insurer files?

DR. BROSEKER: We are looking for February of '98.

DR. ROBINSON: Okay, thanks.

DR. BROSEKER: The registry is going to be updated on a quarterly basis. That is about it. Every couple of months you will be getting a new update to the registry.

PARTICIPANT: I just had a couple of questions, I guess. I presume that this will also provide a payer I.D. to third party administrators or plan administrators that do work on behalf of groups?

DR. BROSEKER: That is correct.

PARTICIPANT: And is there going to be guidance as to telling an employer when they have to have their own payer I.D. and use that? Because there are some that use insurance carriers as administrators, there are others who may be doing some arrangements that are self funded or not self funded. I am just curious: is there some guidance to the employer to know when they have to have a payer I.D. and use that?

DR. BROSEKER: Actually, in addition to developing the regulation, we are also developing guidelines on that line. It also applies to providers as well as payers, because providers could also be a plan, like an HMO. So we want to make sure that everybody understands their role and when they have to use their numbers.

PARTICIPANT: The reason I ask that is, I can see confusion, particularly from employers with multiple health plans, some self funded, some not, in trying to determine when they need to use this and when not to, and obviously also for the provider, trying to figure out when they have to fill that information in for an employer, when they may see two employees come in, and they will have to try to figure out who is the payer in that particular case.

DR. BROSEKER: Yes, we agree. That is a good point.

PARTICIPANT: I just had a follow-up to what you just said about the registry's update on a quarterly basis. If the carriers are to maintain that, but we are only getting new updates every quarter, then I'm not quite sure, if new claims are coming in that need to have new payer I.D., how is that -- they come in on a daily basis, so I'm not quite sure how that is going to be --

DR. BROSEKER: You are talking about Medicare carriers?

PARTICIPANT: Yes.

DR. BROSEKER: They will have access to the payer I.D. registry on a daily basis. You can go in at any time to update your own records. The industry at large will be getting -- if they want a download of that registry copy, they will be getting a quarterly update, so it is a little different. You can have online access, or you can have a copy of the registry. But if you do have a payer I.D., then you can go in at any time to update your own information.

PARTICIPANT: Will medi-gap providers be able to have a default number then?

DR. BROSEKER: At one time we thought we were going to distinguish medi-gap from the rest of the industry. But as it is now, they are going to be considered just like every other insurer out there.

What we are looking to propose is a number that the individual health plan will let us know, is there a default address, that if they want all their claims to be sent to one specific place, they can let us know that, and that will become their default.

DR. POKORNY: You mentioned in response to my first question, you see the health plan acting as the gateway. Does that mean that a health plan as enumerated in the legislation would have one unique identifier, that the concept of the two-digit suffix, which was bandied about many, many months ago, has been set aside?

DR. BROSEKER: Yes. We got some comments from industry, saying that the suffix caused them confusion. So now we are concentrating on the fact that a legal entity will be assigned a payer I.D. That is the full nine-digit payer I.D., will identify that entity.

DR. POKORNY: And only one payer I.D. per legal entity?

DR. BROSEKER: That is correct.

DR. POKORNY: Thank you.

PARTICIPANT: I just had a follow-up to something you said a minute ago about a plan being able to assign a default number. In our case, we have a number of carriers doing business in different states under similar names, and we are planning to use a specific number for all of those plans and then internally sort out the claims. Would we be able to do that under what you just said? Could we assign one default number for all of the companies --

DR. BROSEKER: That's correct.

PARTICIPANT: -- and then the providers would send everything, and then we take care of it.

DR. BROSEKER: That will be your option, yes.

DR. BUCCAFURNO: I have a question to the committee as a whole, not necessarily to the health plan identifier. Perhaps you want to ask if there are any more health plan identifier questions before I go ahead?

DR. BROSEKER: That's okay, go ahead.

DR. BUCCAFURNO: I am from a company called NorTel, Northern Telecom. This question goes to some of the issues you had up earlier about whether a national master patient index was feasible.

My company has been doing national database infrastructures for the telecom industry for a number of years. We see a number of similarities between the technologies that we have been using and the technologies that you will need to implement your national patient identifier infrastructure.

My question was whether you were interested in learning more -- or using my company in an advisory capacity, just to talk further about what the infrastructure might look like.

DR. ABERNATHY: Our team has received some information from your company. As I recall, it was in the form of overheads for some presentation, and we didn't hear the presentation that went with the slides. So I'm sure that our information is not complete, but we do have a way to contact you on that.

DR. BUCCAFURNO: What I sent you was basically a conversation starter, just to give you an idea of the kinds of things we are thinking of. Certainly, information about how this would work would be very detailed and very complex, and probably require a number of subsequent conversations and meetings going forward. If you are interested, contact me.

DR. ABERNATHY: Thank you. It does give me a good opportunity to ask for help from anybody in the audience. It is a difficult process and a difficult recommendation to make.

What I didn't say, if I can take one more minute, in the time that I was up here was that we probably will end up recommending a combination of the best of the recommendations that we have seen. That would be my guess. If there is someone who has spent some time on this and has a recommendation that we haven't seen, we would like to have your input into the process.

Mary gave you her phone number and e-mail, and she would forward anything on to me about the individual identifier, I'm sure.

DR. EMERSON: I'd like to first ask if there are any more questions about the payer I.D. Is that what yours is about?

DR. ZUBELDIA: Yes. Faye, I want to make sure I understood correctly. The proposal that was on the table before was to assign payer I.Ds to large payers in groups of 100 at a time. Has that been killed?

DR. BROSEKER: Yes.

DR. ZUBELDIA: There was also another proposal that was discussed, about having the payers request a specific payer I.D. number that would be maybe similar to the number they are currently using today, and instead of reassigning a random number to the payer, letting the payer select what number they want. Is that possible?

DR. BROSEKER: I think you are referring to -- one of the terms was called vanity numbers?

DR. ZUBELDIA: Yes.

DR. BROSEKER: We looked at that, and currently we are going to propose that we do not want to introduce intelligence into the number. But we welcome your comments when the proposal goes out there.

Are there any other questions about payer I.D.? Thank you.

DR. EMERSON: The last identifier that our team is considering is the identifier for every health care provider. We expect to propose that the national provider identifier that has been under development at the Health Care Financing Administration be used as the provider identifier.

The NPI is an eight-position, alpha-numeric identifier. Like the payer I.D., there is no intelligence in the identifier itself. It has the capacity to enumerate more than 20 billion providers.

Some of the system features that you may be interested in are that we will have data validation software as part of our system. We will have an interchange with the Social Security Administration, where we will be able to send them the SSNs and names of providers that have been reported for NPIs, and they will validate that the name and SSN match what is on their files. We will also have address standardization and validation software as part of the system.

The heart of the system, if you will, is a search and match algorithm that will attempt to prevent assignment of duplicate NPIs to providers. The system has a national database and it will have a query and report generation feature as part of that.

We have three issues that have remained controversial about the national provider identifier, and I would like to go over those briefly right now. The first involves the enumeration of providers on a national scale. We are using the term enumerator to describe the entity that would interact directly with our system, in order to obtain NPIs for providers. So the question really is, what kinds of entities will be the enumerators with the national provider system.

There have been several proposals. I want to mention that what we plan to do is to list these proposals in our notice of proposed rulemaking, and ask for your comment and your vote on what you think would work the best.

I'll go over them briefly right now. First would be that the various federal programs that currently enumerate providers would be enumerators, and would obtain NPIs for their providers, and that the Medicaid state agencies would also be enumerators, and would obtain NPIs for their providers.

We recognize there are many providers that don't deal with either a federal program or a Medicaid program, and so in order to allow them a way to obtain NPIs, we could also establish a registry, and those providers could go to the registry to obtain their NPIs.

Another possibility that has been proposed to us is that the governor of each state would designate a state agency to be the funnelling point for the providers in that state. That way, the state could choose an entity that would work best for it. It could be a Medicaid agency, it could be the state professional licensing boards, or whatever would work best for the state.

A combination of those types of enumerators might also be used. So again, we will be putting forth some options in the notice of proposed rulemaking and asking for your comments on those.

The second issue that has remained controversial about the NPI is whether the system should contain the practice addresses of individual providers, like doctors and other practitioners. Some people have felt that the system should really only contain a mailing address for those providers. Others have felt that every practice address of the provider should be listed in the system.

The issues there really revolve around the difficult and expense perhaps of maintaining the data on those practice addresses. We have learned that they are fairly volatile; providers move around a lot. Should we be trying to keep them up to date in the central system?

Another question has been, if we do collect those practice addresses, should we assign a location code as a pointer to each practice address for the provider? Again, as with the enumeration options, we will be putting forward several options here in the notice of proposed rulemaking and asking for your comments on them. One of the options does contain practice addresses and location codes, one of them does not, and we would like to know your thoughts.

The last issue that has remained controversial is whether the system should contain the Department of Health and Human Services Office of Inspector General sanction information about the providers. Some folks there have felt that this was important information to have in the national file, because it helps plans and other health programs make a wise decision about which providers to enroll in the program.

Others have felt that the focus of the national provider system should be kept strictly on uniquely enumerating the provider, and that we should not bring in other supporting functions like those that might support enrollment of a provider.

So these are some of the issues that we are dealing with. I would like to mention that for both the payer I.D. and the national provider identifier, there is quite a lot of information on the HCFA website, www.hcfa.gov. If you go to the link for initiatives, you can get information on both the payer I.D. and the national provider identifier. The NPI information has just recently been updated and it includes discussions of these issues and the options that you will also see in the notice of proposed rulemaking.

I would like to introduce now Karen Trudell. Karen is the regulation team leader for the national provider identifier effort, and she will take your questions on the NPI.

DR. TRUDELL: Are there any questions on the NPI?

PARTICIPANT: One obvious question I have is, will a group practice be able to get an NPI as the group name, or will each individual provider within the group have to have its own NPI?

DR. TRUDELL: Group practices will be enumerated as entities in and of themselves, and individuals who practice in the groups would also have NPIs as individual practitioners. The system will link the two together.

PARTICIPANT: Okay, because obviously, that is a clear opportunity for HHS debarred providers to hide behind a group in many instances, not to mention the many other ways that they circumvent the system. Are these things being addressed?

DR. TRUDELL: Groups and individuals will be linked within the system.

DR. TRACY: Could you please provide an operational definition of the term provider, and indicate to me which allied health professionals you anticipate being categorized within this term?

DR. TRUDELL: That is an excellent question. It is one that we thought was going to be very easy from the beginning, and it became more problematic as time went by. What we mean by a provider is either an individual or group or an organization that provides health care services or supplies to patients. We expected that in the beginning, this is going to be primarily used by providers who are involved in the electronic transactions that are specified in the HIPAA legislation.

However, over time it appears that we need to take into account the fact that other allied health care professionals, registered nurses, other therapists who perhaps don't often bill directly for their services or engage in the other transactions may either begin to do so in the future or that there would be another reason for them to have a unique identifier, perhaps that would be associated with a computerized patient record in the future.

So we expect that initially, we are going to target enumerating the providers who engage in these transactions, and keep the door open in the future to enumerate any other health care providers. The definition in the regulation is very broad. We haven't left very many practitioners out.

DR. EMERY: Jack Emery with the AMA. I'm just looking for some assurances that the underlying data that is used to help assign a number is information that will be kept in house, not available generally to the public. We have very strong concerns about fraud and abuse of provider numbers by inappropriate people, or data that is contained in the provider files. Will we get that assurance?

DR. TRUDELL: Yes. There is again a line that we are having to define in terms of making certain amounts of data available to the health care industry in general, so that the provider identifier is usable in electronic commerce. There is also data that we expect we will need in order to make a reliable match, demographic data, social security number, date of birth and that type of information is not necessary to maintain electronic commerce and the utility of the NPI, and it would be preserved under the privacy act and kept separate.

The regulation actually delimits two different sets of data elements, and says which ones will be available to the general public and the industry at large, and which ones will be maintained in HCFA's internal file.

DR. POKORNY: How will entities that are integrated as both health plans and providers be enumerated?

DR. TRUDELL: As health plans and as providers.

DR. POKORNY: Separate numbers?

DR. TRUDELL: This is -- yes. This is a situation where it depends more on the function than the entity itself. An HMO could be a provider, it could also function as a plan if it has to handle out of area claims. A hospital obviously is a provider, but it is also an employer. So a lot of these definitions are going to have to be very carefully worked out also across all of the transactions. I think that was one of the things that was mentioned this morning as an issue.

DR. ZUBELDIA: Do you see the provider I.D. being used as the submitter I.D. for electronic transactions?

DR. TRUDELL: As a submitter I.D.?

DR. ZUBELDIA: Yes.

DR. TRUDELL: In terms of who submits a claim and who gets the payment?

DR. ZUBELDIA: In terms of sending the claim, yes, or sending any of the transactions, separate from who is performing the medical service. If that is the case, will service bureaus, for instance, have provider I.Ds?

DR. TRUDELL: In some cases, the entity who submits the claim is not the same person as the one who performed the service. If you have a group practice, who submits the claim? And the payment goes to the physician? Each of those would have a provider I.D., so it definitely has a connotation over and above who actually performed the care.

PARTICIPANT: How about billing services and automated claims clearinghouses? Under the various identifiers, would they be assigned any specific types of identifiers?

DR. TRUDELL: No, unless they are payers. Clearinghouses? No, I'm sorry.

DR. RENSHAW: If the provider is the submitter, would they have separate numbers, one for the physician part of it and one for the electronic submission, or one provider I.D. would cover both identifying a provider and the electronic submission?

DR. TRUDELL: Right. One of the challenges we have had is to try to structure this number and the process so that various payers can use the number in whatever ways their own business processes require.

PARTICIPANT: Addressing that issue, I'm not sure I'm clear on that, because there are many doctors who use a billing service that is serving many, many different providers in many, many different locations. Ultimately, especially if it is a managed care plan, certain providers are under the plan and certain providers would be non-participating providers.

It would seem to me that any claim would have to come in with two fields, a field for the provider and a field for where this remittance is going to go to.

DR. TRUDELL: But it might have the same identifier in both fields.

PARTICIPANT: But there has to be the facility t have two separate numbers on the same claim, correct?

DR. TRUDELL: Yes, that's correct. But we view that as a question that has got more to do with the use of the number and the standard encounter or claim form than how we are going to issue the identifiers.

PARTICIPANT: There's a lot more issues to that, because certain providers are licensed to perform certain functions, and other providers are not also. So there are many, many issues related to that, and there has to be the facility for the provider who is doing the service to be on that claim, as well as wherever you want that payment to go to.

DR. TRUDELL: Yes.

DR. TRACY: A comment rather than a question. I think this goes to my earlier question of the definition of a provider. I think there really ought to be two distinctly different concepts here that may require different terms. The legal entity responsible for the care and maybe the recipient of reimbursement from the individual who actually provides the care. It certainly appears as if the two concepts are intertwined in a single term here.

DR. TRUDELL: Yes, that's true. I suppose the only thing I can do is to suggest that as you look at the definitions the way they are in the notice of proposed rulemaking, if there is something that we have missed or if there is something that is going to make it difficult to do business, we need to know about that.

Mary tells me the provider definitions are on the website.

DR. DONATH: It appears that a payer's claim systems in a provider's master file would have to provide enhanced assistance to include many data elements, such as the old number as well as the new number, the stop and start dates. Will you be issuing guidelines as to what other data elements will have to be maintained, any flags or anything along with the unique I.D. number?

DR. TRUDELL: By health plans?

DR. DONATH: For payers. Claims will still be coming in to old healths as well as new numbers. There has to be a stop and start date. So there has to be other fields in the system beside what claim systems have now for providers, which is an additional cost. They have to enhance the systems when they design it.

I was just wondering, will you be giving any guidelines as to what other additional information other than the new number that would have to be maintained.

DR. TRUDELL: There will be guidelines that we will be providing to the Medicare carriers as to how they can implement. We have heard from some of our own carriers and FIs that they would just like to switch over on one day. Others have told us that they would rather do it gradually.

The data elements that we will be making available as I said are noted in the regulation. Some of the data actually points back to old numbers. So if you have existing provider numbers, you would be able to use that data to crosswalk back to them.

DR. MOORE: The last question really was an implementation issue, as Karen tried to address. We have been made acutely aware when we proposed that we would go out and do this first, and enumerate all the Medicare providers, how that might have the potential to cause a lot of grief in the whole community. If we implement it to a provider, what would be the national provider identifier, leaving all the other payers to use their own, and it would cause the providers to try to make a rush to make all the other payers change it.

But it has nothing to do with how we enumerate providers. Once we get them all enumerated, then we have to sit down with you all and decide how is the best approach to do this. Would it be feasible for us to say, on January 1 of the year 2000 we are going to have all providers use a new number? Are we all comfortable with that? I don't know if I am. I don't think the providers would be, too much.

But this is something we have to work out as an implementation issue. Whenever you do anything on this grand of a scale, with this many parties and payers, we are estimating that there are over four million providers and over four million payers, when you count all the ERISA plans and everyone else that is in there. So we are looking at eight million payers in this game, and how do you get everyone to coordinate it and implement something without causing grief to those who haven't done it, or those who are going to do it, can we do it at one time. Those are things we have to work out. No matter how we enumerate providers, we still have that issue to address.

DR. TRUDELL: Thanks, Bob. Are there any other questions? Four minutes to spare. Thank you.