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Back  RFI # 1798: Atypical Providers with an NPI

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Submitter

Peggy Billhartz

Description

5010 835 - An atypical provider is the payee and has a proprietary ID and an NPI, because they have services that are non-healthcare and some that are healthcare. Non-healthcare claims are sent in with the proprietary ID. The only allowable fields in the 5010 835 for payee identification, that are applicable for this business, are the NPI and tax ID. The Payee Additional Identifiers are not applicable.

Can the 835 list the NPI for that atypical provider, since it is on the provider file, even though claims were sent in with the proprietary ID?

Submitter Assigned Keywords

835 Atypical Provider NPI

Response

Although there is no explicit requirement to return the same NPI or Atypical provider ID that was submitted on the claim, the intent and expectation is an identifier should flow through the life cycle of the claim. Reporting an atypical provider as a payee in the 835 is accomplished by reporting the provider’s tax ID that was submitted on the 837 in the 835 1000B Payee Identification, N1 Segment (N103=FI, N104 = tax ID). Additionally, the proprietary number from the 837 - 2010BB REF - Billing Provider Secondary Identification (where REF01=G2 and REF02=Atypical number) can be reported in the 835 1000B REF-Payee Additional Identification Segment, where REF01=PQ and REF02=Atypical number.

Recommendation

Grouping payments under one payee identifier for multiple Billing Providers may only be done when MUTUALLY agreed upon between the provider and the payer. When there is such an agreement, the information transmitted in the TS3 segment will be the Billing Provider values received on the claim. TS3 is not required to be used if there is no such agreement.

Please review RFI 400 and 462 for additional information related to the 835 and NPI
Submission 5/22/2013
Status Date 6/24/2013
Status F - Final
Primary References
Document 005010X221
SectionTable 1
Loop1000B
Segment IDN1
Industry NamePayee Identification