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Back  RFI # 1175: Multiple 837Is per Patient

Formal vs. Informal Help Informal Formal

Submitter

Bob Resh

Description

Section 1.10.3 states "When an organization health care provider has determined that it has subparts requiring enumeration, that organization health care provider will report the NPI of the subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider". This implies that if an organization provider has, for instance, enumerated their lab, they must separate out the lab charges into a separate claim from the inpatient stay charges. For a health plan paying based upon DRG, this would mean that separate claims would be received for the single DRG payment. Is this correct?

Response

No, not necessarily. It depends on how the provider has defined the subpart that was enumerated. The key words are “the most detailed level of enumeration as determined by the organization health care provider.” The enumeration process includes the provider defining the type of business covered by each of its subparts. If the lab charges for inpatient stays are always billed under the non-lab NPI, then that is already the lowest level of enumeration for that type of business, so the NPI would remain the same in 5010. However, if the provider uses the lab NPI for the exact same charges for one payer, but includes them on inpatient stay claim for another payer, then a lower level of enumeration exists for that type of business. A decision would have to be made about whether inpatient lab charges fall under the lab NPI or the non-lab NPI. Then the chosen NPI would be used consistently as the billing provider for that type of charge to all payers.

Recommendation

It is possible that a payer could see some changes in the billing provider NPIs being used on claims, though unlikely in this particular situation.

If providers find that additional billing provider NPIs will be sent to some payers in order to bill consistently to all payers, they should contact the payer not currently receiving those NPIs.
Submission 10/8/2010
Status Date 11/19/2010
Status F - Final
Primary References
Document 005010X223
Section1.10.3
Page42
Set ID837I