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Back  RFI # 461: NPI professional claims

Formal vs. Informal Help Informal Formal

Submitter

Description

From the professional billing perspective(837 P), is there a requirement to identify the Rendering Provider in the 835 (2100 loop) with the same NPI as the Rendering Provider on the claim or can any NPI related to the Billing Provider/Payee be included? Can the Rendering Provider NPI be eliminated completely if we store the information only at the Payee Level?

Submitter Assigned Keywords

NPI, Professional claims NPI

Response

Although there is no explicit requirement to return the same NPI that was submitted on the claim, the intent and expectation was an identifier should flow through the life cycle of the claim.

Recommendation

Based upon the workgroup’s understanding of the rule and business:

Guide 004010X091A1 explicitly requires that the Rendering Provider be identified when different than the Payee. That requirement is not set aside if your system only associates the Payee with the claim today. Since this is the provider that actually rendered the service(s) this must match the NPI from the claim and cannot be just any NPI related to the Payee or the Billing Provider. This does not address business practices associated with how a Payer manages a submitted NPI that differs from what they have in their database.
Submission 10/11/2006
Status Date 11/22/2006
Status F - Final
Primary References
Document 004010X091A1
Section2100
Page111
Set ID835