Section title: Requests for Interpretation
RFI #
2344
Provider Name versus NPI
Description

I have a payer that allows credentialing of physician under our group contracted plan. Full physician first, last and middle name as noted on their state license along with NPI. However, they are not using the rendering NPI on the claim to properly identify the provider but use the physician name first, last but only middle initial. Our claims have the full middle name which results in failure to identify the physician as in network and processes/adjudicates Out of Network and requires appeal/reconsideration.
Per the guide the NPI is required and in this scenario is sent on the 837 and accepted. Is there any documentation to require the use of NPI to uniquely identify the physician?

Response

While the intent of having the NPI in the Loop 2310B or 2420A Rendering Provider NM109 is for it to be used to identify the Rendering Provider, the 837 TR3 has no purview over how a receiver uses the identifying data about a provider within their internal systems and cannot require a receiver to use it for that purpose. The Middle Name or Initial NM104 is “Required when needed to identify the individual”.  Any expectation of Middle Initial only and not full Middle Name should be communicated through the Trading Partner Agreement or Companion Guide.

DOCUMENT ID
005010X222A1