On an 837 from a provider they submit the most detailed organization subpart as the billing provider (loop 2010AA) NPI. What is acceptable in the returned 835 for the Payee (Loop 1000B)?
Provider Main Org:
NPI: 1111111111
Tax ID: 999999999
Subpart:
NPI: 2222222222
NM1*85*2*Subpart*****XX*2222222222~
N3*Subpart Address~
N4*Flagstaff*AZ*860010000~
REF*EI*999999999~
NM1*87*2~
N3*Main Org address~
N4*Flagstaff*AZ*86001~
Are we to return the 2010AA subpart NPI as the payee information? If not, where should this information go in the 835?
N1*PE*WEST YAVAPAI GUIDANCE CLINIC*XX*2222222222~
If the above example is not correct, would we be required to return an NPI even if the main organization did not have an NPI for their “pay-to” location, only the subpart related to that main location or could the Tax-ID for the pay-to be used?
Example:
Main Tax ID: 999999999 (No NPI associated with this location- all services are performed at subpart locations that have NPIs)
N1*PE*Payee*FI*999999999~
Although there is no explicit requirement to return the same NPI that was submitted on the claim, the intent and expectation was an identifier should flow through the life cycle of the claim.
If a subpart was identified in the 837 by NPI, then the "main organization" must have an NPI, and would be reported with the name of the "main organization" in the 1000B loop if considered the payee. The appropriate tax ID, related to the 1099 tax form, is also returned in either case.
If the actual “payee” is not a provider and does not have an NPI, then the N1 segment reports the Tax ID. That payee may have supplemental IDs in the 1000B Payee Additional Identification REF segment.
Recommendation
The provider NPI reported on the claim should be returned on the 835.
Payment can be made to a provider's corporate entity NPI or other NPI than what was received on the claim. However, this may only occur when there is a separate, explicit, notification from the provider identifying the payee and the related Billing Provider NPIs.
When the Payee NPI is other than the submitted Billing Provider, the TS3 segment should be used to group like Billing Provider claims by NPI within the ERA. Within each 2000 loop, the TS301 would identify the billing provider NPI for all claims within that loop.