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Back  RFI # 657: NPI Requirement in the 835

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Submitter

Michii Summers

Description

A payer is sending tax IDs in the N1*PE and REF*PQ segment, pharmacy numbers in LX01, and NPIs in TS301. The tax ID is the same in N1*PE and REF*PQ; however there may be multiple pharmacy numbers and NPIs throughout the 835 file in multiple LX01 & TS301 segments. Is this HIPAA-compliant and does this satisfy the NPI requirement?

Response

Guide 004010X091 is clear on the usage of N103 code XX (NPI) in the 1000B loop. It states "Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used." If the payee is a provider that is covered by the NPI, then the NPI is required in N103/4. If the payee is not a provider or is not covered by the NPI rule, then the Tax ID is appropriate. The note on the 1000B REF segment reads "Use this REF segment only when more than one identification number is required to identify the payee." Therefore, the REF segment must contain a different
ID than the N1. TS301 is listed as the "Provider number". While the guide provides no additional direction, the NPI rule limits what can be used for a covered provider. Consult askhipaa@cms.hhs.gov for HIPAA rule issues. LX01 is an assigned number and has no direct relationship to a provider number in the guide. Therefore, any content in LX01 that is consistent with the data element type and size is compliant.
Submission 5/22/2008
Status Date 7/9/2008
Status F - Final
Primary References
Document 004010x091A1
SectionHeader
Page73
Set ID835
Table1
Loop1000
Segment Position4
Segment IDN1