Use Your NPI

Federal law mandates that health care practitioners use their unique, ten-digit National Provider Identifier (NPI) when submitting standard electronic health care transactions, such as claims. Since August 3, 2009, EmblemHealth rejects claims if the NPI is not correctly populated in 837 electronic claims transactions.

HIPAA has adopted new guidelines for electronic health care transactions. The Version 5010 rules for transactions become effective on January 1, 2012. EmblemHealth will be compliant by January 1, 2012. Compliance with HIPAA requires the use of ANSI ASC X12N (Version 5010) transaction standards and implementation guides.

Revised NPI Requirements for Professional Provider Claims (837P)

• Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
• Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.
• Rendering Provider 2310B: Only required when the Rendering Provider information is different from the information carried in Billing Provider Loop 2010AA. If this loop is sent, an NPI is required.
• Rendering Provider 2420A: Only required when the Rendering Provider information is different from the information carried in the 2310B or 2010AA loops. If this loop is sent, an NPI is required.

Revised NPI Requirements for Institutional Claims (837I)

• Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
• Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.

Revised NPI Requirements for Dental Provider Claims (837D)

• Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
• Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.
• Rendering Provider 2310B: Only required when the Rendering Provider information is different from the information carried in Billing Provider loop 2010AA. If this loop is sent, an NPI is required.

Please contact your practice management system vendor to ensure your software is capturing and correctly populating your NPI in your electronic claims submissions.

Questions?
If you or your system vendor has any questions regarding the above EmblemHealth 837 NPI technical requirements, please contact an EmblemHealth Electronic Media Claims (EMC) Technical Representative at 1-212-615-4362.

HIPAA Transaction Companion Guides
We have made available transaction-specific companion guides to the ASC X12N Implementation Guides adopted under HIPAA. They contain specifications for electronic transmission to EmblemHealth.