Question: May the Billing Provider Loop for the X12 837P be used to report a provider Taxonomy Code for a non-individual provider when the usage notes in the adopted Version of the Implementation Guide requires reporting only in certain situations?
Answer : The Healthcare Provider Taxonomy Code (HPTC) that is permitted for certain situations in the 4010/4010A1 837P Implementation Guide is a 10-character alphanumeric administrative code that identifies the health care provider type, classification, and, for some classifications, the area of specialization of health care providers. The code set is maintained and updated by the National Uniform Claim Committee (NUCC). Health care providers may have more than one HPTC depending on their classifications and specializations, and select their own HPTCs from a list of available codes that is published by the Washington Publishing Company (available at www.wpc-edi.com/taxonomy.) While HPTCs are not health care provider identifiers, they do identify provider type, classification, and/or specialization, which is information that is often needed by health plans to determine claim reimbursement and subscriber benefits.
The Version 4010/4010A1 of the 837P Implementation Guide (for professional claims) states that it is not compliant to send the HPTC in both the Billing/Pay-to Provider Specialty Loop (PRV 2000A) and in the Rendering Provider Identifier loop (2310B), except in certain situations. Only when the Billing and Rendering Provider are the same is it permissible to report the HPTC in the Billing Provider Loop (2000A). The inability to report a Billing Provider’s type, classification, or specialization, except when the Billing/Pay-to Provider is the same as the Rendering Provider, can burden health plans with the need to suspend claims, telephone providers for the additional information, and, in some cases, incorrectly adjudicate claims because needed information is not permitted by the IG to be submitted on the original claim.
This problem with the 4010/4010A1 837P Implementation Guide arose with the implementation of the NPI because the NPI does not contain intelligence about the type, classification, or specialization of the health care provider it identifies; whereas the previously used legacy identifier numbers often did. In order to obtain health care provider type, classification, or specialization information, some health plans are requesting submission of the HPTC in the Provider Specialty Loop (PRV 2000A) when the Billing Provider and Rendering Provider are not the same, even though this is inconsistent with the instructions in the Implementation Guide. For example, an Acute Care Testing medical group may have a number of different specialty providers within the group. In order to adjudicate a claim, a health plan may need to identify the specialty of the billing provider with a taxonomy code in the Loop 2000A PRV segment, even though, according to the 837 P 4010/4010A1 Implementation Guide, this segment is not used when the Billing or Pay-To Provider is a group and the individual Rendering Provider is identified in Loop 2310B.
There is an incompatibility between the 4010/4010A1 Implementation Guide requirements and the business need of the Billing Provider’s type, classification, specialization. Therefore, until the adoption of a new Version of the professional health care claims transaction standard that corrects this problem, CMS will exercise enforcement discretion if HPTCs are reported for Billing Providers in the 837P claims transactions where the Billing Provider and the Rendering Provider are different. Each complaint will be evaluated on a case-by-case basis.
Answer : The Healthcare Provider Taxonomy Code (HPTC) that is permitted for certain situations in the 4010/4010A1 837P Implementation Guide is a 10-character alphanumeric administrative code that identifies the health care provider type, classification, and, for some classifications, the area of specialization of health care providers. The code set is maintained and updated by the National Uniform Claim Committee (NUCC). Health care providers may have more than one HPTC depending on their classifications and specializations, and select their own HPTCs from a list of available codes that is published by the Washington Publishing Company (available at www.wpc-edi.com/taxonomy.) While HPTCs are not health care provider identifiers, they do identify provider type, classification, and/or specialization, which is information that is often needed by health plans to determine claim reimbursement and subscriber benefits.
The Version 4010/4010A1 of the 837P Implementation Guide (for professional claims) states that it is not compliant to send the HPTC in both the Billing/Pay-to Provider Specialty Loop (PRV 2000A) and in the Rendering Provider Identifier loop (2310B), except in certain situations. Only when the Billing and Rendering Provider are the same is it permissible to report the HPTC in the Billing Provider Loop (2000A). The inability to report a Billing Provider’s type, classification, or specialization, except when the Billing/Pay-to Provider is the same as the Rendering Provider, can burden health plans with the need to suspend claims, telephone providers for the additional information, and, in some cases, incorrectly adjudicate claims because needed information is not permitted by the IG to be submitted on the original claim.
This problem with the 4010/4010A1 837P Implementation Guide arose with the implementation of the NPI because the NPI does not contain intelligence about the type, classification, or specialization of the health care provider it identifies; whereas the previously used legacy identifier numbers often did. In order to obtain health care provider type, classification, or specialization information, some health plans are requesting submission of the HPTC in the Provider Specialty Loop (PRV 2000A) when the Billing Provider and Rendering Provider are not the same, even though this is inconsistent with the instructions in the Implementation Guide. For example, an Acute Care Testing medical group may have a number of different specialty providers within the group. In order to adjudicate a claim, a health plan may need to identify the specialty of the billing provider with a taxonomy code in the Loop 2000A PRV segment, even though, according to the 837 P 4010/4010A1 Implementation Guide, this segment is not used when the Billing or Pay-To Provider is a group and the individual Rendering Provider is identified in Loop 2310B.
There is an incompatibility between the 4010/4010A1 Implementation Guide requirements and the business need of the Billing Provider’s type, classification, specialization. Therefore, until the adoption of a new Version of the professional health care claims transaction standard that corrects this problem, CMS will exercise enforcement discretion if HPTCs are reported for Billing Providers in the 837P claims transactions where the Billing Provider and the Rendering Provider are different. Each complaint will be evaluated on a case-by-case basis.
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