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Back  RFI # 652: Provider Secondary ID's

Formal vs. Informal Help Informal Formal

Submitter

Jennifer McMullin

Description

We are a software vendor and have a healthplan customer that is exporting an 837P transaction and sending it to a PPO Repricer. The healthplan is sending the Billing Provider NPI in the 2010AA NM109 Loop (NM108 = XX). The billing provider does not have an Employer Identification Number in the healthplans system, so the requirement to send out the REF segment with an EI qualifier is impossible to satisfy. The PPO vendor is indicating that when the billing provider's EIN is unavailable, that the health plan should be sending the PAY-To providers EIN in the billing provider loop (2010AA) REF*EI segment. First Question: If a billing provider does not have a EIN, is the health plan supposed to be sending the PAY-TO EIN in the 2010AA loop REF*EI segment? Second Question: Since PPO repricers are not covered entities under HIPAA, is there really a requirement to send the REF"EI segment to the repricer? Wouldn't that compliancy requirement be between a provider and a healthplan? Not a healthplan and a repricer?

Submitter Assigned Keywords

REF*EI

Response

Billing Provider Tax ID is a requirement, therefore it seems that it would be available to the health plan in the original submission from the provider.

The second question addresses nonstandard data and the scope of HIPAA. X12N does not offer opinions on an entity's compliance obligations under HIPAA.

Recommendation

X12N's interpretations are intended only to clarify the implementation guides. It is not within X12N's scope to comment on the actions of specific entities such as regulatory bodies, carriers, and providers, nor to render an opinion on an individual entity's compliance with HIPAA or other federal or state regulations. Requests concerning interpretations of the HIPAA regulations as issued by the Department of Health and Human Services should be submitted via email to askhipaa@cms.hhs.gov.
Submission 5/9/2008
Status Date 7/23/2008
Status F - Final
Primary References
Document 004010X098A1
SectionLoop2010
Page87
Set ID837P