Agencies
Services
Provider Notice issued 02/27/09
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MEDI Web site at www.myhfs.illinois.gov
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Fax the Provider or Payee approval letter from the National Payee/Provider Enumeration System (NPPES) with the contact name and phone number to 217-557-8800.
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Mail the NPPES approval letter with the contact name and phone number to:
Important Addendum
This addendum #2 to the February 27, 2009, notice regarding the Elimination of the One-Digit Payee Code for Electronic Claim Submittals, is being issued to advise providers of a delay in the implementation of the Billing Provider NPI for 837P electronic format claims. The first addendum to this notice was issued on April 22, 2009.
This addendum #2, issued by HFS on July 2, 2009, is now considered part of the February 27, 2009 notice.
The July 1st implementation date of using the Billing Provider NPI to derive the payee for claims submitted in the 837P electronic format is being delayed. The department will continue to utilize the dual process. The department will notify providers of the new implementation date in the near future. Providers are encouraged to report the payee NPIs to the department as soon as possible.
Electronic claim submittals that contain both the one digit payee code in Loop 2010AB, REF02 and the Pay-To Provider (Payee) NPI in Loop 2010AB, NM109, will be processed with the Payee NPI not the one digit payee code. DO NOT submit claims with the Pay-To Provider (Payee) NPI unless you have verified with the department that the NPI is registered to the appropriate 16 digit payee number for the provider that you are submitting claims for.
Important Addendum
This addendum to the Informational Notice dated February 27, 2009 regarding the Elimination of the One-Digit Payee Code for Electronic Claim Submittals, is being issued to inform providers of an electronic billing requirement for salaried physicians/professionals who are employed by a FQHC, RHC, ERC.
This addendum, issued by HFS on April 22, 2009, is now considered part of the February 27, 2009 notice.
Physicians who bill fee-for-service, under their own name and NPI and designate the FQHC, RHC, or ERC as their designated payee, must always report their name and NPI as the Billing Provider in Loop 2010AA. The clinic’s name and NPI must be reported as the Pay-To Provider in Loop 2010AB. There is no Rendering Provider information reported. The clinic’s NPI, reported in Loop 2010AB, must be registered to a 16 digit payee number associated with the physician billing fee-for-service.
Elimination of the One-Digit Payee Code for Electronic Claim Submittals
| To: | All Participating Providers & Pay-To Providers (Payees) |
| Date: | February 27, 2009 |
| Re: | Elimination of the One-Digit Payee Code for Electronic Claim Submittals |
This notice replaces the Informational Notice dated October 14, 2008, regarding the National Provider Identifier (NPI) implementation for the pay-to provider (payee). Effective July 1, 2009, the department will no longer accept the one-digit payee code and will begin using the Billing Provider NPI to derive the payee for claims submitted in the 837P electronic format. This will not affect providers using the 837I billing format.
Effective March 23, 2009, the department will implement a dual process for reporting the payee in the 837P electronic format. The dual process will allow providers to continue to report the one-digit payee code or the Billing Provider/Rendering Provider. The dual process period will allow providers to transition from using the one-digit payee code to using the Billing Provider/Rendering Provider NPIs. This will allow time for providers to obtain NPIs for their group practices/organizations and to obtain and register with the department a unique NPI for each of their 16-digit Healthcare and Family Services (HFS) payee numbers.
The 16-digit payee number can be identified on the Provider Information Sheet generated by HFS. It consists of the nine-digit FEIN for the designated payee, the five-digit zip code and a two-digit vendor ID number. Providers have the option of consolidating all active payee numbers into one single payee number. Providers who would like to consolidate their payees should contact the department’s Provider Participation Unit at 217-782-0538.
Providers have the following options to report their NPIs:
Illinois Department of Healthcare and Family Services
Provider Participation Unit
P.O. Box 19114
Springfield, Illinois 62794-9114
Providers can begin reporting the individual practitioner/physician’s name and NPI as the Rendering Provider and the group practice’s name and NPI as the Billing Provider. Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC) and Encounter Rate Clinics (ERC) will report the clinic Name and NPI as the Billing Provider. The name of the practitioner/physician rendering the service at the clinic and his/her NPI will be reported as the Rendering Provider.
837P and Direct Data Entry (DDE) Claims
HIPAA guidelines state the use of the Rendering Provider is situational, except when the Rendering Provider information, NM1 is different than the information reported in either the Billing Provider, NM1 or the Pay-To Provider, NM1. The Rendering Provider Loop is mandated when the Rendering Provider is different from the Billing Provider. For HFS, the Billing Provider and the Pay-To Provider will be the same.
Loop 2010AA, NM1 – Billing Provider Name
Group Practice, FQHC, RHC, ERC, etc. & NPI
Loop 2310B, NM1 – Rendering Provider Name
Individual practitioner/physician’s name & NPI
Loop 2010AB, NM1 – Pay-To Provider Name
Not Required for HFS
Effective with claims received on or after July 1, 2009, the department will no longer accept the one-digit payee code in Loop 2010AB, Pay-To Provider. If a payee cannot be derived from the NPI reported in Loop 2010AA, Billing Provider, the claim will be rejected.
Provider Billing Information – Billing Examples (837P & DDE)
Example 1: Physician billing for an office visit.
Physician: Dr. John Doe = NPI: 1234567890
Payee: Helping Hands Clinic = NPI: 1357913579
Loop 2000A – Billing/Pay-To Provider Specialty Information
Taxonomy Code: Not Required
Loop 2010AA, NM1 – Billing Provider Name
Helping Hands Clinic, NPI: 1357913579
Loop 2310B – Rendering Provider Name
Dr. John Doe, NPI: 1234567890, Taxonomy Code: 207Q00000X
Loop 2010AB – Pay-To Provider Name
Not required; the Billing Provider is the same as the Pay-To Provider
Example 2: FQHC billing for an encounter.
FQHC: One Stop Clinic = NPI: 1357901357
Payee: One Stop Clinic = NPI: 1357901357
Rendering Physician: Dr. Joe Smith = NPI: 1590159015
Loop 2000A – Billing/Pay-To Provider Specialty Information
Taxonomy Code: 261QF0400X
Loop 2010AA, NM1 – Billing Provider Name
One Stop Clinic, NPI: 1357901357
Loop 2310B – Rendering Provider Name
Dr. Joe Smith, NPI: 1590159015, Taxonomy Code Not Required
Loop 2010AB – Pay-To Provider Name
Required only if the Billing Provider is different then the Pay-To Provider
Example 3: Salaried physician rendering services at a hospital owned clinic
Physician: Dr. Sally Jones = NPI: 1246801246
Payee: Southern IL Hospital = NPI: 1480148004
Loop 2000A – Billing/Pay-To Provider Specialty Information
Taxonomy Code: Not Required
Loop 2010AA, NM1 – Billing Provider Name
Southern IL Hospital, NPI: 1480148004
Loop 2310B – Rendering Provider Name
Dr. Sally Jones, NPI: 1246801246, Taxonomy Code: 207Q00000X
Loop 2010AB – Pay-To Provider Name
Not required; the Billing Provider and Pay-To Provider are the same.
Example 4: Hospital billing fee-for-service for labs and x-rays
Hospital: Western Memorial Hospital = NPI: 1680124601
Payee: Western Memorial Hospital = NPI: 1680124601
Loop 2000A – Billing/Pay-To Provider Specialty Information
Taxonomy Code: 282N00000X
Loop 2010AA, NM1: Billing Provider Name
Western Memorial Hospital, NPI: 1680124601
Loop 2310B: – Rendering Provider Name
Not required; the Rendering Provider and the Billing Provider are the same.
Loop 2010AB: – Pay-To Provider Name
Not required; the Billing Provider and Pay-To Provider are the same.
Example 5: Atypical Provider, Medicar transport
Transportation Provider: S & K Transportation = HFS Provider Number: 332244556001
Payee: S & K Transportation = HFS 16-digit Payee Number: 332244556 60601 01
Loop 2000A – Billing/Pay-To Provider Specialty Information
Taxonomy Code: 343800000X
Loop 2010AA, NM1 – Billing Provider Name
S & K Transportation, FEIN: 332244556 (Qualifier 24, NM108)
Loop 2310B – Rendering Provider Name
Not required; the Rendering Provider and the Billing Provider are the same.
Loop 2010AB – Pay-To Provider Name
Not required; the Billing Provider and Pay-To Provider are the same.
Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.
Theresa A. Eagleson, Administrator
Division of Medical Programs