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Back  RFI # 2217: 837P - 2310C Serv Facility NPI

Formal vs. Informal Help Informal Formal

Submitter

Mary Winter

Description

Can the Service Facility NPI contain an individual providers NPI, if the Service Facility is a sole proprietorship?

ex. Provider bills a claim where the member was seen by the provider’s physician at a remote facility (billing provider rents space and equipment). The Service Facility is owned by a sole proprietorship (and only has an individual NPI) and is not a subpart of the Billing Provider. The Service Facility (2310C) Name, Address and NPI is entered with the Entity Type 2.

The payer edits the claim and determines that the Service Facility NPI is an individual’s NPI (based off the NPPES registry) and rejects the claim, due to the entity types not matching.

Can the payer assume that the Service Facility must be an organization’s NPI (Entity Type = 2)?

Is it permissible for the payer to validate the EDI entity type for a Service Facility’s NPI against the NPPES registry?

Response

The Entity Type Qualifier submitted on claims will not always match the Entity Type within NPPES. The edit as described would result in a claim which is conformant to the TR3 being rejected.

The Entity Type Qualifier submitted on a claim in NM102 and the Entity Type in NPPES represent similar but not identical information.

The NPPES Entity Type indicates that the NPI is issued to an individual (Type 1) or an organization (Type 2). A sole proprietorship would be issued a Type 1 NPI since it is owned by an individual and it does not exist apart from that individual.

The Entity Type Qualifier within the claim indicates if the reported entity is a person or a non-person. Since a location is not a person, a Service Facility Location is always reported with an Entity Type Qualifier of 2 non-person entity. The entity which owns the Service Facility Location can be a sole proprietorship (NPPES Entity Type 1) or an organization (NPPES Entity Type 2).
Submission 5/31/2017
Status Date 12/1/2017
Status F - Final
Primary References
Document 005010X222
Section2300
Page269
Table2
Loop2310C