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Formal vs. Informal Help Informal Formal


Robert Huffman


A 270 has a Receiver NM1 segment that includes an identifier using the combination of NM108 and NM109. The 270 receiver can also have a REF segment for additional information. My problem is when the NPI is used.
How would a provider report their NPI in the NM1 segment and their Medicare ID? When NPI is mandated for use, it seems that a provider cannot send to Medicare their Medicare provider ID in a REF segment. The '1C' - Medicare Provider ID in the REF in loop 2100B states "This code is only to be used when the information source is not Medicare. If the information source is Medicare, the Medicare provider number is to be supplied in NM109 using ID code qualifier 'SV' in NM108.Since we are Medicare and we will be the source, how can a provider supply us with both pieces of data when the NPI is mandated for use and in the interim period when NPI can be used but not mandated?


This issue is explicitly addressed in guide 004010X092. The note on the 2100B loop REF segment position 1 code HPI reads "The Health Care Financing Administration National Provider Identifier may be used in this segment prior to being mandated for use." Therefore, prior to mandated use of the NPI, the NPI can be conveyed in the REF segment using code HPI in REF01 and the Medicare Provider number can be conveyed in the NM1 segment with qualifier SV in NM108. Once the NPI is mandated, the NPI will be conveyed in the NM1 segment using qualifier XX. At that time, there will be no way to convey the Medicare Provider Number in the REF segment.

The purpose of the NPI is to eliminate the need for providers to maintain identifiers that only apply to specific payers. Once the NPI is mandated for use, there would be no need to send a payer specific provider identifier (e.g. Medicare Provider Number, Medicaid Provider Number, etc.).
Submission 8/10/2005
Status Date 10/3/2005
Status F - Final
Primary References
Document 004010X092A1
Set ID270
Segment Position030
Segment IDNM1
Element Position08
Code ValueXX
Secondary References
RFI ID 263
Document 004010X092A1
Set ID270
Segment Position040
Segment IDREF
Element Position01
Code Value1C