What Is The Service Facility On Claims
A frequent issue among those working with HealthChoices information is accurately identifying the specific location where outpatient services are rendered, peculiarly when the provider delivering intendance has more than one service location. The difficulty stems from the differing requirements for identifying providers in HIPAA EDI transactions vs. the PA DHS MIS, PROMISe™, likewise as the different formats employed for reporting claims information in HIPAA EDI transactions vs. PROMISe™.
Identifying Providers in HIPAA EDI Transactions
Nether the HIPAA Authoritative Simplification Rule, wellness intendance providers are required to submit electronic claims for payment equally encounters using a standardized format. This is unremarkably referred to as Electronic Information Interchange, or EDI. Healthcare claims are to be submitted in 837 format; 837 Institutional (837 I) transactions to bill claims for care delivered past hospitals and skilled nursing facility locations, and 837 Professional person (837 P) transactions to neb claims for care delivered by physicians, suppliers and other not-institutional providers at both outpatient and inpatient facility locations. ane (An outpatient service may be delivered in a facility setting or a non-facility setting. A facility is a infirmary, skilled nursing facility (SNF) or convalescent surgery center (ASC). A non-facility is an outpatient setting like a clinician's office or outpatient clinic. For services that can exist billed as either facility or not-facility, payments are lower when billed as facility-based vs. non-facility-based service.)
Another requirement of the Authoritative Simplification Rule is that all providers have a standard number to identify themselves on healthcare transactions; the National Provider Identifier (NPI). The NPI is a x-digit "intelligence free" number, which means that it does non carry any other information near a provider other than their identification.
Information about the kind of care a provider offers is communicated in Taxonomy codes. A Taxonomy code is a unique ten-graphic symbol alphanumeric lawmaking. Each code has three distinct levels: Level I = provider blazon, Level Two = classification, and Level Three = surface area of specialization that enables a provider to identify the care they are qualified to deliver. Taxonomy codes tin be assigned at either an individual provider or at an arrangement level. A provider can annals for any Taxonomy lawmaking(s) they wish.
While the goal of the Administrative Simplification Dominion was to found mutual standards and identifiers to simplify the exchange of information, its implementation has at times complicated the identification of a provider's service location. There are several reasons for this ambiguity. One reason is that there are no standard rules regarding the number of NPIs for which a provider may apply. Some providers have only ane NPI, merely many role locations. For these providers, the specific service location cannot exist derived solely from their NPI. Another reason is that there is no logical connexion between a provider's Taxonomy codes and their service locations.
Besides, while the HIPAA 837 P transaction layout always requires the billing provider exist reported on the come across for outpatient services, the rendering provider information is non always required. 2 (The 837 Implementation Guide states that the Rendering Provider loop is "situational" and is not a "syntactically required loop". However, the loop is "required when the Rendering Provider information is different than that carried in either the Billing Provider or the Pay-to-Provider loops.) For HealthChoices BH encounters, if the rendering provider is not reported, it is assumed to be the same as the billing provider.
Farther complicating the recording of provider information on HIPAA 837 P transactions is that the information is recorded in dissimilar sections, or "loops", on the run across layout. All billing provider data is recorded in one loop; 2010AA. When the rendering provider is present, its NPI and taxonomy code are recorded in loop 2310A; however, the service location is recorded in a different loop; 2310C – Service Facility Location Secondary Information.
Identifying Providers in Hope™
In Promise™, providers are identified by their Master Provider Alphabetize (MPI), which is comprised of a nine-digit number for the provider parent system + iv-digit number for the provider service location. Each thirteen-digit MPI is associated with a single address, and so a provider with multiple offices will take a distinct MPI for each location. Providers are required to enroll every service location where they provide services to Medicaid recipients in club to receive reimbursement for services rendered there. PA DHS recently reiterated this requirement in bulletin 99-eighteen-11.
When a provider enrolls with PA DHS, each MPI is mapped to the provider's NPI and nine-digit aught code. If more than one MPI service location falls within the same 9-digit zip code for a given NPI, for instance if a provider enrolls under more one provider type at the same location, PA DHS distinguishes among the locations using the different Taxonomy codes associated with the NPI.
Although PA DHS uses Taxonomy codes to distinguish among the locations associated with a provider's NPI, they practise not use Taxonomy codes to describe the type of care a provider offers. Instead, PA DHS uses combinations of Provider Type and Specialty. Providers may enroll nether one or more Provider Type and Specialty combination, depending on the blazon of care they provide.
Unfortunately, there is not a 1:1 relationship between a Taxonomy lawmaking and a combination of Provider Type and Specialty, merely rather each combination of Provider Blazon and Specialty can map to more than i Taxonomy code, as shown hither.
| Prov Blazon | Provider Type Description | Provider Specialty | Provider Specialty Description | Taxonomy Lawmaking | Taxonomy Description |
|---|---|---|---|---|---|
| 11 | Mental Health /Substance Corruption | 110 | Psychiatric Outpatient | 251K00000X | Agencies Public Health or Welfare |
| eleven | Mental Wellness /Substance Abuse | 110 | Psychiatric Outpatient | 251S00000X | Agencies Community Behavioral Wellness |
| xi | Mental Health /Substance Abuse | 110 | Psychiatric Outpatient | 261Q00000X | Ambulatory Wellness Care Facilities Clinic/Center |
| xi | Mental Health /Substance Corruption | 110 | Psychiatric Outpatient | 261QM0801X | Convalescent Health Intendance Facilities Clinic/Center Mental Health (including customs Mental Health Centre) |
| eleven | Mental Health /Substance Abuse | 110 | Psychiatric Outpatient | 261QM0850X | Ambulatory Health Care Facilities Clinic/Heart Developed Mental Health |
| 11 | Mental Health /Substance Abuse | 110 | Psychiatric Outpatient | 261QM0855X | Ambulatory Health Intendance Facilities Dispensary/Center Adolescent and Children Mental Health |
The Claims Life Cycle
To understand how these different provider identifiers, claims formats and requirements touch on the accuracy of deriving a service location, it'south useful to review the basic life cycle of Medicaid electronic claims filing:
- 1. The provider submits an electronic claim to the insurer, typically in HIPAA EDI 837 HealthCare claims format
- 2. The insurer adjudicates the claim and translates it, if needed, to meet the detail requirements of the land MIS
- iii. The 837 run across is submitted for adjudication to the state MIS
Pennsylvania has idiosyncratic processing requirements related to provider identification which must be satisfied for 837 encounters to be successfully adjudicated. Specifically, Promise™ requires a valid rendering provider MPI, rather than the NPI, which is the identifier mandated by HIPAA EDI format on 837 encounters.
The simplest way to comply with the Hope™ requirement would exist for the insurer (in this case the Behavioral Health Managed Care Organizations or BH-MCOs) to require providers to include the 13-digit MPI of the rendering provider on each 837 service line. Since each xiii-digit MPI is associated with just one accost, there would exist no ambiguity nigh service location. Nonetheless, HIPAA EDI format does not mandate the inclusion of the rendering provider MPI on claims; therefore, payers cannot impose this requirement on providers.
Information technology is therefore up to the BH-MCO to either derive the rendering provider MPI from the information on the claim, or submit the claim without deriving the MPI, in which case it will be derived in Promise™ during adjudication, using the crosswalk PA DHS has established to derive MPIs on incoming Fee-for-Service (FFS) claims.
The Crosswalk betwixt NPI and MPI
To facilitate the MPI derivation process for BH-MCOs, DHS provides a crosswalk between 13-digit MPIs and information elements that tin can exist required on an 837 claim under HIPAA:
In theory, it should be possible for the BH-MCO to derive the right MPI from those elements, and therefore identify the exact service location. In practise, however, this process often imposes unreasonable demands on the submitter. Consider the provider shown, Marsha Brown. three (Provider identifiers and demographics accept been de-identified.)
| NPI | Taxonomy | Taxonomy Clarification | MPI | Prov Type | Prov Type Description | Proper noun | Zip Code | Address | City |
|---|---|---|---|---|---|---|---|---|---|
| 8153663010 | 103T00000X | Behavioral Wellness and Social Service Providers | 5183014030006 | 19 | Psychologist | BROWN, MARSHA | 009158341 | 106 Church ST | GREENWAY |
| 8153663010 | 103T02000X | Cognitive & Behavioral | 5183014030004 | xix | Psychologist | Brownish, MARSHA | 009158341 | 108 Church ST | GREENWAY |
| 8153663010 | 103T00000X | Behavioral Health and Social Service Providers | 5183014030005 | 19 | Psychologist | Dark-brown, MARSHA | 009158453 | 56 MORRIS RD | FISHERSVILLE |
| 8153663010 | 103T00000X | Behavioral Health and Social Service Providers | 5183014030003 | nineteen | Psychologist | Brown, MARSHA | 009158532 | 3405 ROSE LANE | OAKVIEW |
| 8153663010 | 103T00000X | Behavioral Health and Social Service Providers | 5183014030001 | 19 | Psychologist | Chocolate-brown, MARSHA | 009158536 | 1627 JACKSON DR | OAKVIEW |
| 8153663010 | 103T00000X | Behavioral Health and Social Service Providers | 5183014030002 | nineteen | Psychologist | Chocolate-brown, MARSHA | 009167013 | 404 W 28TH ST | MANSFIELD |
Suppose the billing provider sends Marsha Brown'due south NPI equally the rendering provider identifier. There are several possible service locations from which to choose when crosswalking the rendering provider on the encounter submitted past the provider to a rendering provider MPI at a service location on the encounter submitted to Promise™. To decide the service location on the encounter for submission to Hope ™, the insurer would presumably wait to the service facility location address on the 837 submitted by the provider. Simply, fifty-fifty if the service location is present, mapping to the right rendering provider MPI could still poses challenges for several reasons:
- ane. Address matching is complicated by the fact that there are different ways an accost may be represented (due east.g. 404 Due west 28th St, 404 Due west 28th St., 404 E. 28th Street, etc.);
- 2. The nine-digit zip code provides a less ambiguous element on which to friction match – only in the case of Marsha Brown, at that place are 2 different locations that share the same nine-digit zip code
- 3. There are likely some claims that contain inexact, incomplete or wrong service facility data
Suppose the billing provider sent the correct 9-digit zero code for the service location, but it happens to map to the zip code for the two rendering provider MPIs in Greenway. The insurer could use the Promise™ strategy for distinguishing amidst locations sharing a mutual zip code, merely this would require the billing provider to utilise 2 different (capricious) Taxonomy codes to distinguish between the 106 Church building Street and 108 Church Street locations.
Changes on the Horizon
Potential changes to both the HIPAA EDI standards and Hope™ MIS are on the horizon. The American National Standards Institute (ANSI) is in the process of developing the adjacent version of EDI standards, 7030™. According to the public review and comment schedule posted by X12, which is the organization chartered by ANSI to develop EDI standards, a second public review of 837 transaction standards is pending. And, the PROMISe™ system is slated for replacement by the end of 2020 with a new organization, currently brainstorm referred to as the MMIS 2020 Platform. Whether or not the standards and system changes will bring more clarity to the process of determining the service location for outpatient services, though, remains to exist seen.
Source: https://www.acainc.com/determining-the-service-location-for-outpatient-services/
Posted by: lawrenceutaltorge70.blogspot.com
0 Response to "What Is The Service Facility On Claims"
Post a Comment