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Back  RFI # 1531: Rendering Providers in 837P

Formal vs. Informal Help Informal Formal

Submitter

Ron Hess

Description

The 5010 837P TR3 (pg 262) states that Rendering Provider is “Required when the Rendering Provider data information is different than that carried in Loop ID-2010AA – Billing Provider.” Is this difference based on either name or NPI, or must both be different?

We compare the NPIs of the Rendering and Billing Provider in accordance with our validation software. We have been approached by our (re-pricing client) to possibly reconsider how we determine same vs. different for these two provider data loops. There are a number of instances where the Billing Provider may be a group w/ the same NPI as the individual Rendering Provider.

Since not all providers in a group are necessarily considered ‘in-network’, our re-pricing client is unable to properly calculate payment of the correct allowance when the Billing Provider is a group and no Rendering Provider is sent in the 2310B Loop because the two data loops (2010AA and 2310B) appear to be the “same” due to like NPIs.

Submitter Assigned Keywords

837p rendering billing provider NPI

Response

The situational rule for 2310B/NM1 states "Required when the Rendering Provider Information is different than that carried in Loop ID-2010AA Billing Provider. If not required by this implementation guide, do not send."

If either the name or NPI is different, the 2310B loop is required.

Therefore, if the rendering provider information, which is inclusive of the NPI and provider taxonomy, is the same as the billing provider, and the 2310B information is submitted, this does not comply with the TR3.
Submission 2/23/2012
Status Date 6/14/2012
Status F - Final
Primary References
Document 005010X222
Section3
Page262
Set ID837P
Table2
Loop2310B
Segment Position2500
Segment IDNM1