Page History

Nomenclature

/Concepts

FHIR element

aka

Definition

Notes/Links               

Who

Patient

Policy

Contract

Legal agreement between a policy holder and an insurer to outline the terms and conditions for certain services rendered  to covered parties

Mary Kay

Patient

 An individual who has received, is receiving or intends to receive health care services.

(Health care services as defined by federal and state regulations.)

 NUCC

Not defined by NAIC

Laurie/1st Pass

Provider

Sonja

Types of Insurance

Focus on Healthcare

Mary Kay

Policy Holder

 The individual or organization which has arranged? with the insurer to provide insurance for health services for a defined group or a named list of beneficiaries.

4/20/2020:  Chat comment.

from David Riddle to everyone:
https://www.healthinsuranceproviders.com/what-is-a-medical-policyholder/
from David Riddle to everyone:
Interesting summary of one perspective on what is a Policyholder

 Example where it does not work - someone buys coverage for their grandkids but the parent (custodial) is called the policy holder (even if not the person who pays for it)

https://www.healthinsuranceproviders.com/what-is-a-medical-policyholder/

Paul

Subscriber

 An individual or entity that selects benefits offered by an entity, such as an employer, government, or insurance company.

Gail/1st Pass

Subscriber Id

Gail

Dependent

 An individual, other than the subscriber, who has insurance coverage under the benefits selected by a subscriber.  

Gail/1st Pass

Dependent Id

Gail

Member

 Any individual covered by the benefits offered by an entity, such as an employer or insurance company.

Laurie/1st Pass

Member Id

Laurie

Beneficiary

Any individual that selects or is covered by benefits provided by government programs

Linda

Period (eligibility)

When policy in force

? Coverage

Gail

Payor

Public or private party which offers and/or administers health insurance plan(s) or coverage and/or pays claims directly or indirectly.  Examples include:

• Insurance Company
• Health Maintenance Organization
• Medicare
• Third-party Administrator
• Repricer

David

Class

Serafina

-Group

-Subgroup

-Plan

Robin

-Subplan

-Class

-Subclass

-Sequence

-Rxbin

 Rxbin

BIN ANSI Issuer Identification Number (IIN)

Rx bin

Rxbin

RxIIN

BIN Number

RxBin - Stands for bank identification number, though it doesn't involve banks and is used to accurately route claims to pharmacy benefit managers (PBM).

The pharmacy industry uses RxBin (required), RxPCN (situational) and RxGrp (situational) to identify pharmacy benefit plans.

RxBIN and RxPCN is analogous to the U.S. zip code + 4. RxBIN (or BIN number), is like the 5-digit zip code that determines the routing destination, and RxPCN (or processor control number), is like the +4, providing a more specific destination.

NCPDP Processor ID Number (BIN) is a six-digit number that health plans use to process electronic pharmacy claims if the health plan doesn't use pharmacy benefit cards with a magnetic stripe. Plans that use cards with a magnetic stripe should use the recommended American National Standards Institute (ANSI) Issue Identifier Number (IIN) for processing electronic pharmacy claims. ANSI issues IIN numbers. NCPDP issues the Processor ID Number (BIN).

Prescription drug routing information, known as 4Rx data, are the four data elements used to process a pharmacy claims.

In Medicare Part D, these four elements uniquely identify the Medicare Part D Sponsor for the beneficiary and are identified by the sponsor during beneficiary enrollment.

The set of four elements are exchanged with CMS contracted entities during eligibility verification, claims processing, and information reporting transactions, as well as post adjudication claim reporting functions.

The 4Rx data are: RxBIN, RxPCN, RXGRP & RxID. 4Rx data allows payment on behalf of the beneficiary to be counted toward TrOOP. (True Out-of-Pocket costs paid by a beneficiary or others on the beneficiary’s behalf that accumulate towards the annual out-of-pocket threshold)

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/NCPDP-Pharmacy-Identification-Specifications-Information.pdf

NCPDP BIN: https://ncpdp.org/Resources/NCPDP-Processor-ID-(BIN)

ANSI IIN: https://www.ansi.org/other_services/registration_programs/iin

NCPDP Guidance Documents: https://ncpdp.org/Resources/Guidance-Documents.aspx

NCPDP Pharmacy Card Fact Sheet: https://ncpdp.org/NCPDP/media/pdf/NCPDPpharmacyIdCardFactSheet.pdf

Mapping NCPDP Pharmacy Card to X12N 270/271 (eligibility): https://ncpdp.org/NCPDP/media/pdf/Rx_id_card_map_to_270-271.xlsx

NCPDP Medicare Part D Resources: https://ncpdp.org/Resources/Medicare-Part-D

Serafina

-Rxpcn

 Rxpcn

RxPCN - the Processor Control Number is a secondary identifier used in routing of pharmacy transactions (as noted above, and analogous to the +4 of a nine digit Zip Code +4.

A PBM/processor/plan may choose to differentiate different plans/benefit packages by assigning unique PCNs to them.

PCN is alphanumeric and assigned by PBM/processors making this identifier unique only to their business and there is no registry of PCNs.

The PCN appears on the pharmacy ID card with the BIN/IIN in accordance with rules defined in the NCPDP Pharmacy ID and Combination Card Implementation Guide. This document is available with NCPDP membership. General information is available on the Guidance Documents page under the "Pharmacy and Healthcare Identification Cards" banner.

Not all entities use the PCN to differentiate plans. Some entities may use the Group ID; still others may not need this level of differentiation.

Serafina

-Rxid

For members who have Medicare part D, this is the patient's member number in the PBM’s system that processes claims

Serafina

-Rxgroup

Each PBM has many groups. Rxgroup identifies the group in which the member is enrolled so claims can be process efficiently and correctly. This is not the Employer Group ID for medical claims.

Serafina

Program

 OMB Circular No. A–11 (2015)
AND/or
AO-05-734SP A Glossary of Terms Used in the Federal Budget Process

Tony

Product

Order

 The order of application of the insurance to health care claims relative to the other insurance policies (Coverages) which an individual may have. This order would generally follow the order convention for Coordination of Benefit and would include consideration of both health care and accident based insurance. 

? Account Coverage.priority

Paul

Network

Bob

Copay

-GP Office Visit Copay

-Specialist Office Visit Copay

-Emergency Copay

-Inpatient Hospital Copay

-Tele-visit Copay

-Urgent Care Copay

-Copay Percentage

-Copay Amount

-Deductible

-Maximum Out of Pocket

-CoInsurance

Exception

-Retired Exception

-Foster Exception

Subrogation

Contract

Contract ID?

Type