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Back  RFI # 602: X098 Pay-To Provider

Formal vs. Informal Help Informal Formal

Submitter

Jennifer McMullin

Description

We're trying to determine the pay-to provider when a billing provider is submitted in the 2010AA loop and a rendering provider is submitted in the 2420A loop, but NO pay-to provider is submitted in the 2010BA loop. The 2010BA loop is not required when the pay-to is the same as the billing provider loop. What happens, however, when a rendering provider is submitted in the 2420A loop, but no pay-to is provided in the 2010BA loop. Is the rendering the pay to or is the billing provider the pay to provider?

Response

The structure of provider information in the claim transaction only allows for a Pay-to provider to be requested as different than the Billing Provider by reporting that Pay-To entity in the 2010AB Pay-to
Provider loop. This structure is clarified by Note 1 of the 2010AB Pay-to Provider Name NM1 segment that reads "Required if the Pay-to Provider is a different entity than the Billing Provider." This is further supported by the payee tax number associated with the payment only occurring in either the 2010AA Billing Provider Secondary Identification segment or in the 2010AB Pay-to Provider Secondary Identification.

Recommendation

If the Rendering Provider is the same as the Pay-to Provider but different than the Billing Provider, the Rendering Provider 2310B loop is not used. In that case, the value of "PT" in the 2000A PRV01 data
element indicates that the Pay-to provider rendered the services. If the Rendering Provider is reported with no separate 2010AB Pay-to Provider loop, the provider to be paid is assumed to be the entity in
the 2010AA Billing Provider loop.

Rendering Provider is reported in the 2420A loop when the rendering provider for that service line is different than the rendering provider indicated at the claim level, which could be the 2010AA Billing Provider, 2010AB Pay-to Provider, or 2301B Rendering Provider as explained above.
Submission 9/6/2007
Status Date 6/17/2008
Status F - Final
Primary References
Document 004010X098A1
Section2010AB
Page95
Set ID837
Secondary References
RFI ID 539
Document 004010X098A1
Section2420A
Page486
Set ID837