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Back  RFI # 1706: Locum Tenens & Orig Prov.

Formal vs. Informal Help Informal Formal

Submitter

Claudette Sikora

Description

On the current ASC X12 837 TR3, version 5010, how can Medicare have submitters report both the locum tenens provider and the provider for whom he/she is substituting?

Medicare law requires ID’ing on a claim both the locum tenens and the individual provider for whom the substitution occurred. In addition, Medicare has identified fraudulent activity necessitating the identification of both providers on a claim. The 5010 837 P TR3 requires ID’ing the locum tenens provider in the Rendering Provider Loop, but there is no additional location to also identify the original provider. The Billing Provider Loop is inadequate for this purpose when group practices are involved. Also, Medicare must validate the original provider as enrolled in Medicare and cannot do so for a provider missing from the claim. Further, the locum tenens provider need not be enrolled in Medicare and may not necessarily have an NPI. Medicare has found that submitters typically omit the locum tenens provider to ensure Medicare payment, and report only the original provider. There appears to be no way of reporting both, and only a means of showing the locum tenens provider in locum tenens situations.

Submitter Assigned Keywords

Medicare; locum tenens; fraud

Response

Within guide 005010X222, the TR3 Note # 1 for the Rendering Provider NM1 segment includes "In the case where a substitute provider (locum tenens) was used, enter that provider's information here."


Therefore, the locum tenens provider is reported as the rendering provider.


There is currently no mechanism for reporting the original/missing provider. Reporting of the original/missing provider is planned for inclusion in a future guide.
Submission 11/13/2012
Status Date 5/21/2013
Status F - Final
Primary References
Document 005010X222
Section2.4
Page262