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Back  RFI # 1426: Provider Contract Plan ID

Formal vs. Informal Help Informal Formal

Submitter

Tia Martinez

Description

As an MCO, we currently have providers that bill under the same organization NPI but are paid different rates depending on certain factors (members/populations served, service location, etc). Currently in the 4010A1 837I/P we require providers to submit a provider's contract Plan ID unique to the benefit plan that the claim should be paid under in Loop 2010AA REF02 in order to pay the claim correctly. In the 5010 IG the verbiage for the Billing Provider Secondary ID has changed to state that it can only be included if 2010AA NM109 is not included AND it is required to identify the provider, yet in the examples/business scenarios it shows the NPI AND this segment being used. Can we still use this segment for the contract plan ID and if not is there anywhere else in the transactions that we can obtain the provider's contract plan ID? Perhaps 2010BB NM109?

Response

The 2010BB REF Billing Provider Secondary Identification segment must only be sent when the NM109 in Loop 2010AA (NPI) is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If the NPI is sent in Loop 2010AA, this segment cannot be sent. Example 1 is incorrect. The Loop 2010BB REF segment should not be in the example. Finally, the Loop 2010BB NM109 is used to identify the Payer.

Recommendation

The 5010 837 transactions are not designed to carry a Provider's contract ID. When applicable, the contract ID is established between the provider and the health plan and maintained in the health plan's internal applications.
Submission 10/4/2011
Status Date 12/6/2011
Status F - Final
Primary References
Document 005010X222
Section2.4
Set ID837
Table2
Loop2010BB
Segment IDREF
Element Position02
Industry NameBilling Provider Secondary Identifier
Secondary References
RFI ID 1875
Document 005010X223
Section2.4
Loop2010BB
Segment IDREF
Element Position02
Industry NameBilling Provider Secondary ID