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Back  RFI # 632: Subst ID/name for 2ndary Prov

Formal vs. Informal Help Informal Formal

Submitter

Martin Jensen

Description

In Medicare's guidance to its billers, it states:

"If, after several unsuccessful attempts to obtain the NPI from the ordering, referring, attending, operating, other, service facility provider, or purchased service provider; CR 5890, from which this article is taken, requires that (effective May 23, 2008) the provider or supplier who is furnishing the services or items report their own name and NPI in the claim’s ordering/referring/attending/operating/other/service facility provider/purchased service provider fields." (MLN Matters Number MM5890)

Using an ID/name other than that of the actual referring/ordering/etc. provider in the data element so designated seems a clear violation of the standard. Please advise.

Also, if a secondary provider does not have an NPI (and is not required by law or contract to obtain one), what should the biller use instead?

Submitter Assigned Keywords

NPI, Secondary Provider, Referring Provider,

Response

The 837 Implementation Guides contain usage and content requirements for the listed provider roles in conjunction with the services reported on a given claim; for example, Attending Physician. Name and Identification Code data elements are for the reporting of information pertaining to the person or entity performing the provider role designated by the Entity Identifier (NM101) qualifier in that loop.

The Trading Partner Agreements section of the Implementation Guide’s Purpose and Overview (Frontmatter section 1) states that trading partner requirements may not modify the requirements in the Implementation Guides. It further states that trading partner requirements may not modify the definition, meaning, or intent of the Implementation Guide.

Regarding the usage of NPI, when the Implementation Guide requires a provider ID, the use of NPI is required when mandated by the NPI rule. Other identifiers are available in the guide when NPI is not required by the rule.

Recommendation

For those provider roles that require the reporting of an identifier, when that provider does not have an NPI we recommend that the submitter report an alternate, non-NPI identifier. The Implementation Guide conditions for requiring an identifier have not changed with the implementation of NPI. Therefore, submitters must have reported an identifier for these provider roles prior to NPI. It would be reasonable for trading partner requirements to specify which identifier is preferred by the health plan.

Note that some of the provider roles listed in this question only require an identifier if known by the submitter. In those cases, it is valid to report the provider name and no identifier when the submitter can not obtain that identifier.
Submission 2/18/2008
Status Date 5/5/2008
Status F - Final
Primary References
Document 004010X098
Section3.1
Page282
Set ID837
Loop2310A
Segment PositionNM109
Industry NameREFERRING PROVIDER NAME