Single NPI Billing and the Missing Loop 2310B

This article discusses an X12/5010 incompatibility seen at many clearinghouses and carriers, indicating they have not properly updated their systems to the X12/5010 standard.

The problem only affects EMS claims*. If your clearinghouse has this problem, then they probably do not have many EMS customers, nor much experience meeting the needs of EMS providers. You should consider switching to a better clearinghouse.

*With a few exceptions. The folks at Therabill have wrestled with the same issue in the broader world of medical billing. They wrote this article to describe their own workarounds for it.


The X12/5010 Standard

Here is the page from the actual standard, explaining when loop 2310B must be present or absent:

loop 2310B specification

This represents a change from the old 4010 standard. In 5010, which became law via HIPAA in 2012, the claim must not contain loop 2310B unless "the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider".

Because this requirement only went into force in 2012, and because it only affects single-NPI entities such as EMS providers, some clearinghouses never implemented this change in their software.


How The Standard Looks In Practice

When an EMS provider performs its billing under a different NPI than it operates under, its claims should look like this:

EDI header
Loop 1000A: EDI sender
Loop 1000B: EDI recipient
Loop 2000A: Billing provider taxonomy (PRV*BI)
Loop 2010AA: Billing provider name, NPI, EIN

Loop 2000B: Primary insurance type
Loop 2010BA: Primary insurance subscriber
Loop 2010BB: Primary insurance name, payor ID
Loop 2300-CI: Claim settings
Loop 2300-DTP: Date of occurrence
Loop 2300-AMT: Patient copay
Loop 2300-REF: PAN, patient record number
Loop 2300-CR1: Ambulance reasons
Loop 2300-CRC: Ambulance certifications
Loop 2300-HI: Diagnosis codes
Loop 2310B: Rendering provider name, NPI, EIN
Loop 2310B-PRV: Rendering provider taxonomy (PRV*PE)

Loop 2310E: Ambulance pickup address
Loop 2310F: Ambulance dropoff address
Loop 2320: Secondary insurance type
Loop 2330A: Secondary insurance subscriber
Loop 2330B: Secondary insurance name, payor ID
Loop 2400: Procedures
EDI trailer

Whereas an EMS provider that uses the same NPI for operations and for billing must send claims like this:

EDI header
Loop 1000A: EDI sender
Loop 1000B: EDI recipient
Loop 2000A: Rendering provider taxonomy (PRV*PT)
Loop 2010AA: Rendering provider name, NPI, EIN

Loop 2000B: Primary insurance type
Loop 2010BA: Primary insurance subscriber
Loop 2010BB: Primary insurance name, payor ID
Loop 2300-CI: Claim settings
Loop 2300-DTP: Date of occurrence
Loop 2300-AMT: Patient copay
Loop 2300-REF: PAN, patient record number
Loop 2300-CR1: Ambulance reasons
Loop 2300-CRC: Ambulance certifications
Loop 2300-HI: Diagnosis codes
(Loop 2310B omitted)
Loop 2310E: Ambulance pickup address
Loop 2310F: Ambulance dropoff address
Loop 2320: Secondary insurance type
Loop 2330A: Secondary insurance subscriber
Loop 2330B: Secondary insurance name, payor ID
Loop 2400: Procedures
EDI trailer

AngelTrack implements this standard exactly.

The problem is, the clearinghouse doesn't understand that an EMS organization is the biller and the renderer.

Clearinghouses are accustomed to how a doctor's offices file their claims. In a doctor's office, the overall practice is the billing provider (i.e. the office that does the billing), and then the individual doctors are the rendering providers (i.e. the people who actually treat patients). So when EMS sends a claim in which the EMS organization is the biller and the renderer, the clearinghouse thinks it's a mistake.

The 5010 specification adopted in 2012 makes allowance for EMS providers in this situation, but that provision has not been fully implemented by all billing software in the wild.


Why This Problem is Limited to EMS Providers

The issue of single NPI billing is mostly limited to EMS providers, because most other healthcare organizations utilize "Group NPI" billing, like this:

Even a single-doctor practice may be structured this way:

Alternatively, a single-doctor practice can actually bill its claims under a single NPI:

...but that is very different than how a single NPI EMS provider will bill its claims:

As a result, most clearinghouses never encounter an EMS-style claim, a claim whose billing provider and rendering provider are a single organization, rather than a single individual.

This issue often manifests as a problem with the taxonomy code

If your clearinghouse is complaining about your taxonomy code, you may actually be suffering from this single NPI problem. As you can see above, taxonomy codes are specified differently in a biller/renderer situation than they are in a single NPI situation:


Workaround: Forcing Loop 2310B Via REF*G2

AngelTrack can be compelled to emit loop 2310B in a single NPI situation, as a workaround for a non-compliant clearinghouse or carrier.

This is accomplished using the REF*G2 mechanism, which is used to specify the rendering provider's alternate ID number. An alternate ID number can be anything, can be assigned by anyone, for any purpose. AngelTrack permits you to input all of your alternate ID numbers, and to select among them for each claim.

REF*G2 is sometimes referred to as CMS-1500 box 24j.

Because the alternate ID is specified in a REF*G2 segment within loop 2310B, if you select an alternate ID, then AngelTrack must emit the entire loop 2310B in order to include the REF*G2 segment containing the alternate ID. The clearinghouse doesn't care about REF*G2 (since it is only used by carriers), and so the claim may sail through.

To use this workaround, you must enter your company's alternate ID number(s) in the Business Identification page under Settings. You can specify as many different IDs as you like, along with a description to help you remember which is which. The numbers don't even have to be real; you can just make one up. (You can deactivate and reactivate your alternate IDs at any time.)

Once you've created one or more alternate IDs, they will appear as a choice in the Coding page, like this:

Coding page showing secondary ID choices

If you designate one of your alternate IDs as the ☑ Default, then that ID will be automatically selected in the Coding for every claim, which would be appropriate if implementing this workaround at the clearinghouse level (i.e. using the workaround for all claims). Otherwise -- if no alternate ID is marked as the default -- then "[None]" will be automatically selected, leaving it to the biller to choose an ID as necessary, which would be appropriate if implementing this workaround at the carrier level (i.e. if using the workaround only for specific carriers).

This is a very iffy workaround

This workaround may satisfy a non-compliant clearinghouse or carrier, but just the same it may cause rejections from other carriers.

The fact of the matter is, the X12/5010 spec prohibits any claim from specifying the same NPI as the biller and as the provider. You can force AngelTrack to do so anyway, but you will likely encounter rejections from other carriers who correctly enforce the spec.



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