If a provider is a sole practitioner with only a Type 1 NPI. They have a DBA Name different from the individual name which is attached to the NPI in NPPES. Should they submit the 837 with both the Billing Loop 2010AA and Rendering Loop 2310B even though the NPI would be the same? Or would this be inappropriate because the 2310B NM109 would NOT be different from 2010AA NM109 violating the situational rule of 2310B?
John Doe Individual NPI 123456789 DBA ABC Massage Therapy.
Billing Loop NM1
NM1*85*2*ABC MASSAGE THERAPY*****XX*1234567890~
Rendering Loop NM1
NM1*82*1*DOE*JOHN****XX*1234567890~
According to the situational rule, the Rendering Provider should only be sent if different than the Billing Provider. Front matter section 1.10.3 further clarifies that an organizational NPI should only be used for the rendering provider when it is associated with an external entity from the billing provider. From an X12 perspective, the above scenario is allowed if the NPI used is an individual NPI. RFI 1531 addresses the data that is used to match whether the Billing Provider and the Rendering Provider are the same.
The rendering provider loop should use a provider’s individual NPI when they are internal to the organization represented in the billing provider loop.
Related RFIs: 1428, 1505, 1531, 1989