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Back  RFI # 1810: 837 Inst 2420A Loop

Formal vs. Informal Help Informal Formal

Submitter

Jane White

Description

In the 837 Institutional in the 2420A loop, Operating Physician we are not receiving NM108 and NM109 data elements on some of the incoming claims. Since this loop is for the “Operating Physician” we do not understand how this could be a atypical provider without an NPI. The lack of the NPI is causing us some issues and we would like clarification in what circumstances would an operating physician be an atypical provider so that we can address the issue.

Response

The Situational Rules of the NM108 and NM109 segments within Loop 2420A reads:

Situational Rule: Required for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI.

OR

Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.

OR

Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.

If not required by this implementation guide, do not send.

If the provider identified in this segment has or is eligible for an NPI, then NM108/09 are required.

Recommendation

It is outside ASC X12’s purview to identify the requirements under which providers are eligible to be an operating physician or to identify procedures which are categorized as surgical. Please refer to the appropriate licensure/certification/registration entities or coding authority for that information.
Submission 6/11/2013
Status Date 7/19/2013
Status F - Final
Primary References
Document 005010X223
SectionDetail
Page456
Table2
Loop2420A
Segment Position5000
Segment IDNM1
Element Position09