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Back  RFI # 2280: Same Svc Addr, external NPI

Formal vs. Informal Help Informal Formal

Submitter

Tia Martinez

Description

We have situations where Physician Billing Services exist in Hospitals which result in claims being submitted with a Service Address that is the same as the Billing Address so that the external entity NPI (e.g. the facility) can be reported in loop 2310C.

So the claim is as follows:
Billing Provider: Physician Service with an NPI and Tax ID pertaining to the Physician Service Entity.

Billing Provider Address: 123 Demo Address

Service Facility: Facility NPI that is maintained under a completely separate entity and Tax Id from the Billing Provicer.

Service Facility Address: 123 Demo Address

So as you can see the facility and billing entity have the same address and yet the HIPAA guideline states the address must be different. When the Loop 2310C is included, the Address information is required. We are receiving rejections from our state agency for this issue. What is the recommended approach?

Submitter Assigned Keywords

2310C, Service Address Required when reporting external entity NPI

Response

This issue is explicitly addressed in the 005010X222A1 TR3. The Loop 2310C Service Facility Location Name is “Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send.” If the Service Facility location is the same address as that reported in the Loop 2010AA Billing Provider Name, the 2310C Service Facility Location Name must not be sent.

Also, Section 1.10.3 Organization Health Care Provider Subpart Representation reads in part:

In published versions prior to 5010, the Billing Provider may have been a variety of entities, including billing services and healthcare clearinghouses. Beginning with version 5010, the Billing Provider must be a health care or atypical service provider (as described in the section entitled Providers who are Not Eligible for Enumeration).

If the billing provider is an actual physician group, located at the same address as the hospital, but is a separate entity from the hospital the actual address location would be expected to be different in that there is a specific suite or building # from the facility address itself.
Submission 4/2/2018
Status Date 5/11/2018
Status F - Final
Primary References
Document 005010X222A1
Section2.4
Set ID837
Loop2310C
Segment IDN3