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Back  RFI # 1270: 5010 835 2100 Rendering Prov

Formal vs. Informal Help Informal Formal

Submitter

Tony Voris

Description

During testing, we've identified a question related to the 5010 835 2100 NM1 Service Provider segment.

Incoming 837P
2010AA
NM1*85*2*DOE CLINIC*****XX*1111111111~

2310B
NM1*82*1*DOE*JOHN*K***XX*2222222222~

The 835 created is:
N1*PE*DOE CLINIC*XX*1111111111~

CLP*xx*1*85*0*58.71*12*xx~
SVC*HC:97012*25*0**1~
REF*HPI*2222222222~
SVC*HC:98941*60*0**1~
REF*HPI*2222222222~

Within our adjudication system, we store the Rendering Provider at the Service level. The 5010 835 IG does not identify if the 2100 NM1 Service Provider segment should be built based on the "Submitted" or "Adjudicated" Rendering Provider information. Could you clarify the requirement and if we should be using the Submitted 837 Rendering Provider information instead of the way we stored the information on our adjudicated claim record to generate the 2100 NM1 Service Provider?
Is the way we are reporting the Rendering Provider data on the 835 considered compliant per the 5010 IG?

Submitter Assigned Keywords

5010 835 NM1 2100 Rendering Service Provider

Response

According to the guide, the rendering provider should be reported at the 2100 Claim level NM1 rather than the service level unless there are variations. In your example, the 2100 loop is inaccurate in that the Payee didn't render any services for the claim. The 2100 NM1 for Service Provider Name should have been present from a technical accuracy perspective, because of the NM1 rule: "Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send." By sending 2310B NM1*82 etc., in the 837, the provider is indicating that this requirement is operative. The rendering provider is different than the billing provider/payee.

Given your 837P example, your 835 example should look like this:

N1*PE*DOE CLINIC*XX*1111111111~

CLP*xx*1*85*0*58.71*12*xx~
NM1*82*1*DOE*JOHN*K***XX*2222222222~
SVC*HC:97012*25*0**1~
SVC*HC:98941*60*0**1~

Recommendation

We suggest that you move the first service line rendering provider to the claim level and report variation in other 2110 loops, as appropriate.
Submission 3/11/2011
Status Date 5/12/2011
Status F - Final
Primary References
Document 005010X221
Section2.4
Page146
Set ID835
Table2
Loop2100
Segment IDNM1
Industry NameService Provider Name