Rendering NPI vs Billing NPI

What is Rendering NPI and where it will get printed?

If the practitioner rendering the service is part of a billing group, the individual practitioner’s National Provider Identifier (NPI) should be reported in the Rendering Physician # area (2310B loop, segments NM108 [XX] and NM109 [NPI], of the 837P electronic claim or Item 24J of the CMS-1500 paper claim form).

• Note: If you submit claims on the CMS-1500 paper claim form, report the NPI of the individual practitioner in the lower, non-shaded portion of Item 24J. No information should appear in the upper, shaded portion of Item 24J, as your claim will be returned to you as unprocessable.

• The NPI is required for all rendering providers. If the NPI is missing, invalid, or submitted in the wrong area (e.g., valid NPI submitted in the upper, shaded portion of Item 24J), your claims will be returned as unprocessable.

What is Billing NPI and where it will get printed?

The billing entity’s National Provider Identifier (NPI) should be reported in the 2010AA Billing Provider Loop of the 837P electronic claim or Item 33a of the CMS-1500 paper claim form. Do not place any information in the 837P 2010AA loop, REF02 (item 33b of the paper form), as it is no longer used.

Important note: The NPI of the billing provider is required on all claims. Claims will be returned as unprocessable if:

• Any information appears in the 837P 2010AA loop, REF02 (item 33b of the paper form). This item should be left blank.

• The billing provider’s NPI is missing, invalid, or is located in the wrong area (e.g., valid NPI submitted in Item 33b.)

Reminder: When billing services rendered by an individual associated with an incorporated entity or a group, the individual practitioner’s NPI must be reported in the Rendering Physician’s area (the 2310B Rendering Provider Loop of the 837P electronic claim or Item 24J of the paper claim form) and the billing entity or group identifier would be reported as indicated above. If billing services for an Independent Lab, Ambulatory Surgical Center (ASC), Independent Diagnostic Testing Facility (IDTF), Ambulance Supplier, or solo practitioner not associated with a group, a rendering provider identifier in Item 24J or loop 2310B is not required.


When do I need to report a rendering provider on my claim?

If your Pay-to provider is a multispecialty or single-specialty group you must declare the NPI of the individual who provided the service in box 24J of the CMS 1500 or in Loop 2310B segment NM109 of the 837P. Please be aware the rendering provider must be an individual that is enrolled with Idaho Medicaid as a part of your group. There are no exceptions to this rule and this will always be required on the claim.

When do I need to report a rendering provider on my claim?

If your Pay-to provider is a multispecialty or single-specialty group you must declare the NPI of the individual who provided the service in box 24J of the CMS 1500 or in Loop 2310B segment NM109 of the 837P. Please be aware the rendering provider must be an individual that is enrolled with Idaho Medicaid as a part of your group. There are no exceptions to this rule and this will always be required on the claim.

On Electronic EMC form

837P Segment/ Data Element 837P Data Element 837P Location/Loop 


Rendering Provider NPI

 Rendering Provider NPI (Service Line Level) Loop 2420A, NM 109 (NM108 = XX)

 Rendering Provider NPI (Claim Level)   Loop 2310B, NM109 (NM108=XX)

Billing Provider NPI Billing Provider NPI Loop 2010AA, NM109 (NM108=XX)

Billing Provider TIN Billing Provider TIN Loop 2010AA, REF02 (REF01=EI)

Billing Health Care Provider Taxonomy Health Care Provider Taxonomy Code Loop 2000A, PRV03 (PRV01=BI)

On UB 04 FORM

The claim level Rendering Provider (Loop ID 2310D) is required when the Rendering Provider is different than the Attending Provider. For Medicare purposes this is required under federal regulatory requirements that call for a “combined claim”, that is, a claim that includes both facility and professional components (Critical Access Hospital Claim billing under Method II, Federally Qualified Health Centers, and Rural Health Clinics). The line level Rendering Provider is required when the Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). Again, for Medicare purposes this is required under federal regulatory requirements that call for a “combined claim,” that is, a claim that includes both facility and professional components (Critical Access Hospital Claim billing under Method II, Federally Qualified Health Centers, and Rural Health Clinics*).

• Place the line item Rendering Physician National Provider Identifier (NPI) in Form Locator 43 (Revenue Code Description) for the line item that contains the services identified.


Do providers need Type 1 (Individual) and Type 2 (Organizational) NPIs?

A. All eligible individual providers (such as physicians, nurses, chiropractors, and physical therapists) are required to obtain a Type 1 (Individual) NPI. Providers who are in a solo practice and who bill currently with their Social Security Number or sole proprietorship Tax ID number may continue to bill as solo practitioners using only their Type 1 NPI. Per the regulation, individuals who have incorporated their practice must also obtain an organizational Type 2 NPI for their corporation. When billing, the individual Type 1 NPI will  be used to identify the provider who performed the service, while the organizational Type 2 NPI will identify the group or entity to be paid.

Individual health care providers who are part of an incorporated group practice will have an individual Type 1 NPI; the practice or clinic must obtain an organizational Type 2 NPI for the group for claims submission purposes.

Large corporations may have many groups working under a shared Tax ID number as DBAs. Since each DBA has its own BCBSIL billing number, each DBA may consider
obtaining and using its own Type 2 NPI to maintain the one-to-one relationship.


Can a group of individual providers who are sharing an office space obtain one Type 1 NPI for all the individual practitioners to share?

A. No. An Individual Type 1 NPI cannot be shared. Each individual health care provider that may render health care services must obtain their own Individual Type 1 NPI. The Type 1 NPI of the rendering provider who performs the service is reported on claims, in addition to the appropriate billing NPI.


If my professional group practice has an Organizational (Type 2) NPI, in addition to my Individual (Type 1) NPI, which NPI number do I submit on claims?

A: To correctly submit 837 Professional Health Care Claims to BCBSIL, the sender’s billing and pay-to provider information must be included in the correct loops. The billing provider’s information must be contained in loop 2010AA, the pay-to provider information must be contained in loop 2010AB, the referring provider information must be contained in loop 2310A, and the rendering provider information must be contained in loop 2310B. To correctly submit 837 Institutional Health Care Claims to BCBSIL, the billing, pay-to provider, attending physician name, operating physician name, service facility name, and other provider name must be included in the correct loops. The billing provider’s information must be contained in loop 2010AA, the pay-to provider information must be contained in loop 2010AB, the attending physician name must be contained in loop 2310A, the operating physician name must be contained in loop 2310B, the other provider name must be contained in loop 2310C, and the service facility name must be contained in loop 2310E

IMPORTANT NPI BILLING INFORMATION:

Do not put the rendering provider NPI in the billing loop of the claim. Rendering information must go in the rendering loop and billing information must go in the
billing loop. Claims will be rejected if billed incorrectly.

Q. Where do I include my NPI on the CMS-1500?

A. The following fields are used for entry of the NPI:

Field 17b: Enter the NPI of the referring, ordering, or supervising provider.
Field 24j (unshaded): Enter the NPI of the rendering provider.
Field 32a: Enter the NPI number of the service facility location.
Field 33a: Enter the NPI number of the billing provider.

NOTE: As of May 23, 2008, the use of only the NPI is required on all claims—claims that include the BCBSIL provider number will be rejected



Filing Claims with NPIs

Your NPI is used for claims processing and internal reporting. Claim payments are reported to the Internal Revenue Service (IRS) using your tax identification number (TIN). To appropriately indicate your NPI and TIN on UB-04 and CMS 1500 claim forms, follow the corresponding instructions for each form included in this manual. Remember, claims processing cannot be guaranteed if you have not notified Blue Cross of your NPI, by using one of the methods above, prior to filing claims. See the first part of this section for more details on how to submit claims to Blue Cross.


For more information, including whom should apply for an NPI and how to obtain your NPI, visit our website or CMS’ site at  www.cms.hhs.gov/NationalProvIdentStand. If you have any questions about the NPI relating to your Blue Cross participation, please contact us at 1-800-716-2299, option 3.




Referring Physician NPIs

Referring physician NPIs are required on all applicable claims filed with Blue Cross and HMO Louisiana. Place the NPI in the indicated blocks of the referenced claim forms:

• CMS -1500: Block 17a

• UB-04: Block 78

• 837P: 2310A loop, using the NM1 segment ad the qualifier of DN in the NM101 element

• 837I: 2310D loop, segment NM1 with the qualifier of DN in the NM101 element

For more information on NPIs, visit www.bcbsla.com/providers >NPI.


Claims Billing Requirements for Primary Care Physicians and Specialists Reminder

This is an update about information contained in the Blue Cross and Blue Shield of Texas Provider Operations Manual. For access to the latest Provider Operations Manual, go to www.bcbstx.com.

Blue Cross and Blue Shield of Texas (BCBSTX) wants members enrolled in Medicaid Managed Care to receive the best possible care. For this to occur, we believe it is important for our members’ Primary Care Provider (PCP) to oversee all medical care, even when members are referred to another provider for services. However, we also realize there are cases where other providers will make referrals for our members. This referral requirement, outlined below, is also requested by the Texas Health and Human Services Commission (HHSC) and helps us to achieve this goal. This process also ensures that your referral-related claims are processed quickly and efficiently.

Reminder about the Claims Billing Referral Requirement

Currently, specialists and other providers must obtain a referral from a BCBSTX member’s PCP or referring / ordering provider prior to treating that member. The PCPs and referring / ordering providers should provide their National Provider Identifier (NPI) to specialists when referring Medicaid Managed Care members and must maintain a record of that referral in members’ medical records. Effective September 1, 2013, BCBSTX will begin denying claims from physicians who have not included the referring provider’s NPI on the claim.

National Provider Identifier Numbers Required on All Claims

To indicate a referral has been obtained, the referring provider’s name must be entered in Box 17 and the NPI must be entered in Box 17b of the Centers for Medicare and Medicaid Services (CMS) CMS-1500 claim form or in Loop 2310A for electronic data interchange (EDI) claims when submitting claims to BCBSTX. If the referring provider is affiliated with a Federally Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC), the provider may submit the Type I/Individual NPI or the Type II/Group NPI.



Providers can obtain the NPI from the referring provider’s office or from the NPI Registry website at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do


Please note: This billing requirement is only for referrals and does not change the current Prior Authorization requirement and guidelines. Refer to the Provider Operations Manual for details about Prior Authorization.


Exceptions

The following Primary Care Physician types do not require a referring NPI:

Family Practitioner Internal Medicine OB/GYN
General Practitioner Nurse Practitioner Physicians Assistant
General Pediatrics


The referring NPI is not required when billing for the following services:

Services from OB/GYNs                       Emergency Services

Services from Indian Health Providers          Family Planning

Urgent Care Center Services                    Health Education

Health Department Services                    Inpatient Services

Anesthesia Services                            Immunizations/administrations

Ambulance Services                            STD/HIV Services – Testing and
Treatment



Other Exceptions

The member has not been assigned a PCP;

Newborn visits for the first 30 days of life

Sports physicals

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