Member Identification for Payer Systems

Many laws have recently been enacted that are designed to help protect the identity of individuals. These laws require the discontinued use of the individual’s Social Security Number (SSN) as a means to interact with the Healthcare Payor community.

In most cases, however, an individual's SSN is either the only or the primary component of the Member-ID/Policy-ID. As such, it is printed on membership cards, written communications (such as EOBs, etc.) and is also needed for electronic interaction through web sites, or IVR systems. So a new identifier must be created that is not related to the individual's SSN.

The challenge for the Payor community is that the SSN has often been used as the key to access the existing backend systems. It is not reasonable or viable to replace all of these backend systems and so some kind of remediation needs to occur that permits the backend systems to remain largely unchanged, but at the same time allows the external interfaces to be modified in accordance with the appropriate laws.

It will be necessary to assign a Member/Policy identifier in place of the SSN, and within the remediation layer convert the new identifier to the old SSN-based identifier, so that the changes to the backend systems are minimized. The core capability of the remediation approach is the ability to intelligently swap the new Member/Policy identifier with the legacy SSN-based identifier.

The impact of the SSN mandate is that either the existing backend systems are updated/replaced to remove dependence on the SSN as a required Member/Policy identifier, or these systems are remediated in some manner. Remediation is clearly attractive as it can be layered on top of the existing backend systems, and the implementation is much less risky than updating all of the core systems.

The remediation layer is used to insulate the backend systems from change, limiting that change to the customer facing systems. These customer facing systems may need to be modified if the new member/policy identifier is longer that the existing, or has migrated from being numeric to alpha-numeric

The remediation layer must contain a master index database so that the new identifier can be cross-referenced and exchanged with the old SSN based identifier. Additionally, an integration component will provide connectivity to the front-end and back-end systems, and locate all instances of the identifier within the data.

The NextGate MatchMetrix EMPI satisfies the requirements for the master index database. The MatchMetrix EMPI maintains the relationship between the SSN and the new identifier, and will exchange one for the other as dictated by the workflow. The EMPI Reporter and Event Tracker and Manager will provide detailed audit trails and histories to comply with regulations, as well as facilitate troubleshooting and management.