If the insurance company that you are submitting to is telling you that your claims need to have a rendering provider, then you will want to read this article. This is an issue that began because of new rules set up during the 5010 conversion.
This article will talk about the NPI and the two different versions of it. The type 1 (individual) NPI and the type 2 (organizational) NPI. Here are some other articles on that you may want to read on this subject.
Why is this happening?
This usually occurs when you have your type 1 (individual) NPI entered under Admin in Therabill (as the billing provider) and you are submitting it as an organizational NPI. If the payor that you are submitting to is expecting a group NPI, you will receive this error. The rule with 5010 is that if the billing provider NPI (Box 33A of the CMS-1500) is the same as the rendering provider NPI (Box 24J of the CMS-1500) then the rendering provider is left out of the electronic claim. That is, if it is the same NPI, then it is assumed it is the same person and it would be redundant to include the information twice.
What do I need to do to fix this?
If you are receiving this error from CHAMPUS Tricare and you are submitting under a Type 1 (individual) NPI as your billing provider NPI, then you will need to fax a letter to Tricare on company letterhead. Include the following on the letter.
- Your Tax ID
- Your NPI
- Your name
- Your phone number
In the letter, include the following statement.
<your name here> as the provider are billing as an individual provider, billing with a TPO of type 1.
Sign the letter (remember it needs to be on company letter head), and then fax it to the following.
- Tricare West
- Attention: Provider Data Management
- Fax Number: (855) 831-7044
- Tricare South
- Attention: Provider Data Management
- Fax Number: (803) 462-3986
Once they process the form, they will contact you at the phone number you listed as your contact phone number. After that, you can go ahead and resubmit your claims.
You have two choices. You can either enter your type 2 (organizational NPI) under Admin in Therabill along with your business name or you should mark your NPI as an Individual NPI (if it is not a group NPI) under Admin.
Entering your type 2 (organizational) NPI
Insurance companies are starting to require that if you are going to submit as a group (with a business name) then you must submit using a type 2 (organizational NPI). You can obtain your type 2 NPI from the NPPES. To submit as a group (business) then you will want to first get your EIN from the government for your tax ID. You can then get your type 2 NPI. You would then want to share that type 2 NPI with your insurance companies to let them know that you will now be submitting under a different billing NPI. Once you have set that all up, you will want to enter your type 2 NPI as your billing NPI in Therabill. This is done by clicking Admin in the top navigation bar (when you are logged in to Therabill) and editing your member information.
In summary, to submit as a group (business), you should have the following entered as the billing provider (Admin) in Therabill: Business name, type 2 NPI, EIN (as the tax ID).
Removing your business name
If you do not have a type 2 (organizational) NPI then you will need to make sure your NPI is marked as an Individual NPI under Admin. You can do this by clicking Admin in the top navigation bar and clicking the Edit button at the top right of your Member Info.
In summary, to submit as a solo practice, you should have the following entered as the billing provider (Admin) in Therabill: type 1 NPI, SSN (as the tax ID).
What about any clearinghouse authorizations I have completed in the past?
The clearinghouse authorizations are attached to the billing NPI. If you change your billing NPI, then you will need to redo the authorizations.