Saturday, October 30, 2010

EDI loop for billing, pay to and rendering provider info

Electronic Data Interchange

The Health Insurance Portability and Accountability Act (HIPAA) requires compliance with the Electronic Data Interchange (EDI) standards. Providers should follow the HIPAA transaction and code set requirements as found in the National Electronic Data Interchange Transaction Set Implementation Guides. The following provides details from the Implementation Guides to accommodate NPI within the 837 and 835 EDI transactions. Failure to comply with the 837 standards will result in a rejection of the claim.

837 Health Care Claim Submissions

PROFESSIONAL
Loop
 Segments/Data Elements
Billing Provider
Loop 2010aa
 NPI:  NM108 = XX and NM109 = NPI
Tax ID: REF01 = EI and REF02 = Tax ID Legacy ID not mandated for use
Pay-To Provider
Loop 2010ab
 NPI:  NM108 = XX and NM109 = NPI
Tax ID: REF01 = EI and REF02 = Tax ID Legacy ID not mandated for use
Referring Provider
Loop 2310a
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Rendering Provider Name
Loop 2310b
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Purchased Service Provider
Loop 2310c
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Service Facility Location
Loop 2310d
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Supervising Provider Name
Loop 2310e
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Rendering Provider Name
Loop 2420a
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Purchased Service Provider Name
Loop 2420b
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Service Facility Location
Loop 2420c
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Supervising Provider Name
Loop 2420d
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Ordering Provider Name
Loop 2420e
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
Referring Provider Name
Loop 2420f
 NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use
Legacy ID not mandated for use
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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download