Example 02: Provider Level Status

ABC Insurance is both the Medicare Part A Fiscal Intermediary and a PPO. ABC insurance has a payer identification of 12345.

XYZ Service, which is a Clearinghouse, has an electronic transmitter identification number of X67E that it uses to conduct electronic business transactions with ABC Insurance.

Home Hospital and Home Hospital Physicians use XYZ Service to submit electronic claims and claim status requests to ABC Insurance. Home Hospital's National Provider Identifier (NPI) is 1666666661. Home Hospital Physicians' National Provider Identifier (NPI) is 1666666666.

The following details are for 2 claims that XYZ Service requested status and ABC Insurance responded:

Claim 1

Request: Fred Smith is a Medicare enrollee with a health insurance claim number of 123456789A. Mr. Smith's birth date is 12/10/1930. A claim status tracking number of ABCXYZ1 was assigned to the status inquiry for Mr. Smith's claim. Home Hospital requested the status of a claim for inpatient services (bill type 111) for services August 31, 2005 through September 6, 2005 in the amount of $8,513.88. Home Hospital provided a patient control number of SM123456.

Response: ABC Insurance assigned a payer claim control number of 05347006051 to Mr. Smith's claim. The claim was pending waiting on additional information that had already been requested.

Claim 2

Request: Joseph Mann is a dependent under John Mann's PPO plan. John Mann is the insured, or subscriber, and his member identification is 345678901. Joseph Mann's birth date is 11/01/1995. A claim status tracking number of ABCXYZ3 was assigned to the status inquiry for Joseph Mann's claim. Home Hospital Physicians requested the status of a service (99203) on May 1, 2005 in the amount of $150.00. Home Hospital Physicians provided a patient control number of MA345678.

Response: ABC Insurance did not recognize the electronic business relationship between Home Hospital Physicians and XYZ Service because Home Hospital Physicians' provider number was erroneously transposed in their transmission set-up. Consequently, ABC Insurance responded at this specific Provider Level indicating the provider was not eligible for EDI status