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What Is the Difference Between a Health Plan and a Payer? (PDF)
Workgroup for Electronic Data Interchange Link to more items from this source
July 29, 2014
"By and large, the healthcare industry tends to use the terms 'health plan' and 'payer' synonymously. The HIPAA regulation, however, defines 'health plan' differently than the way the industry commonly uses the term. This variation in terminology usage has also created additional interpretation issues.... Even though an entity can be in both roles, not all payers are health plans and not all health plans are payers. Usage in transactions relies on the identification of the role the entity being identified is playing.... If a health plan, third-party administrator, administrative services organization, or a different entity currently is identified in standard transactions as a payer, it would continue to do so. If the entity currently is identified as a health plan (and continues to be identified as a health plan after November 7, 2016) in standard transactions, it must use an HPID."

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