Can the Service Facility NPI contain an individual provider’s NPI, if the Service Facility is a sole proprietorship? ex. Provider bills a claim where the member was seen by the provider’s physician at a remote facility (billing provider rents space and equipment). The Service Facility is owned by a sole proprietorship (and only has an individual NPI) and is not a subpart of the Billing Provider. The Service Facility (2310C) Name, Address and NPI is entered with the Entity Type 2.
The payer edits the claim and determines that the Service Facility NPI is an individual’s NPI (based off the NPPES registry) and rejects the claim, due to the entity types not matching.
Can the payer assume that the Service Facility must be an organization’s NPI (Entity Type = 2)? Is it permissible for the payer to validate the EDI entity type for a Service Facility’s NPI against the NPPES registry?
The Entity Type Qualifier submitted on a claim in NM102 and the Entity Type in NPPES represent similar but not identical information. The TR3 does not require that the Entity Type Qualifier submitted on claims match the Entity Type within NPPES. In some cases, there is not a way to report the service facility location that is both conformant to the TR3 and satisfies the payer’s requirement that the Entity Type Qualifier on the claim match the Entity Type within NPPES.
The NPPES Entity Type indicates that the NPI is issued to an individual (Type 1) or an organization (Type 2). A sole proprietorship would be issued a Type 1 NPI since it is owned by an individual and it does not exist apart from that individual. In the example given, the patient received services at a remote site. Since the services were rendered at a location other than the location reported in the billing provider loop, it is required to submit the remote location as the Service Facility Location. This value is reported in the 2310C for 837P and 2310E in the 837I. If the service location to be identified has an NPI and is not a component or subpart of the billing provider entity, then NPI is reported in the NM109.
The Entity Type Qualifier within the claim indicates if the reported entity is a person or a non-person. Since a location is not a person, a Service Facility Location is always reported with an Entity Type Qualifier of 2 non-person entity. A Service Facility Location can be the service location of a sole proprietorship (NPPES Entity Type 1) or an organization (NPPES Entity Type 2).