NY Medicaid requires a referring provider for non-emergency transportation providers. NY Medicaid continues to provider Prior Authorizations for non-person entities and requires this to be reported in 2310A referring provider loop. In the 5010 837P guide, you can only report a "person" as the referring provider. I have been instructed to send the non-person entity name in NM103 (last name) with the NPI of the ordering facility in NM109. Is this a valid request per the IG? I've been advised that because non-emergency providers are a-typical, the IG requirements do not pertain to these claims. Please advise if a payor can require this for a-typical providers.
First and foremost, the requirements of the TR3 (Implementation Guide) apply to any and all uses of the TR3 whether the provider is or isn't an atypical provider. The 2310A Referring Provider Loop requires that the referring entity be a person and only a person. Per the version 005010 837 Professional TR3 section 1.8, Trading Partner Agreements, “A trading partner agreement must not override the specifications in this implementation guide if a transmission is reported in GS08 to be a product of this implementation guide.” It is therefore not compliant with the TR3 to send or require that a non-person entity be reported in this Loop.
If a regulatory agency concludes it has a legislative requirement not met elsewhere in the TR3 the administering agency can request a review by the appropriate X12N Work Group for approval to use the K3 segment to meet this need.