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Back  RFI # 767: Intent of the Pay-To-Provider

Formal vs. Informal Help Informal Formal


linda heitman


What is the intent of the use of the Pay-To-Provider?

If the pay-to-provider segment is used does that mean that payment should/must be directed to the pay-to? A lot of payers pay to what is on the contract and in their provider file.

Submitter Assigned Keywords



In the 004010A1X098 Implementation Guide the Pay to Provider loop/segment is intended to be used when the entity to be paid is different than that reported in the Billing Provider loop/segment. The situational note reads: “Required if the Pay-to Provider is a different entity than the Billing Provider.” If the Billing Provider is the entity to be paid, the Pay to Provider is not used.

The Authors of the 004010A1X098 Implementation Guide did not intend for the Billing Provider and Pay to Provider segments to override the payment processes of the payer and any contractual relationships that may exist between the payer and the provider. Ultimately, it’s the responsibility of the payer to determine the appropriate payee. However, in the absence of any other agreement with the provider, the usage of the Billing and/or Pay to Provider segments do provide the information on how a provider wishes to be reimbursed.
Submission 4/22/2009
Status Date 7/6/2009
Status F - Final
Primary References
Document 004010X098A1
Set ID015