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National Provider Identifier (NPI)

We have implemented an EDI front-end editing change for 837 professional claims, effective Jan. 12, 2019.

The two scenarios that result in claim rejection include:

  • NPI is not present in the correct location on the claim form
  • There is a mismatch between the information in the National Plan & Provider Enumeration System (NPPES) and our claims system. (Claims for ABA providers and Corporate Service Providers (CSP) are the exceptions.)

To correct the problem:

  • Include the rendering provider NPI in the correct location on the claim form, and contact your clearinghouse to ensure they are placing it in the correct location
  • If there is a mismatch, call NPPES at (800) 465-3203 to update your information

NPPES will be used as the resource for validating NPI data, so it is important that providers review their NPPES records for accuracy. The NPPES resourced data will be updated monthly, by the 22nd of each month.

Edits will be applied to 837 professional claims only when:

  1. NPI in billing and/or rendering provider segment(s) is valid.
  2. A billing NPI is submitted in NM109 of the 2010AA Billing Provider Loop, with place of service 11 (office) only:
    • If the NPI submitted is a Type 1, then the sole proprietor field must be a Yes
    • If the NPI submitted is a Type 2, then the rendering provider segment must be submitted in Loop 2310B or 2420A

      Note:The rendering provider NPI will not be required at this time, but the segment must be provided with the rendering provider name.
  3. As a reminder, the billing provider Address Loop 2010 must have a physical address. If the services rendered were not at this address, then the Service Facility Loop 2310C must be submitted. If there is more than one service facility for the claim, then use the Service Facility Loop 2420C

Error messages on your 277CA claims acknowledgment and suggested resolutions:

STC*A7:562:85—Invalid billing NPI. Verify the billing provider NPI is valid. If valid, verify it is active on NPPES.

STC*A8:562:85—Invalid billing provider relationship. Verify the billing provider is a solo practitioner or an organization. If the billing provider is a member of a group, the group’s information, including NPI, should be in the 2010AA; and rendering provider information in 2310B or 2420A. If you are a solo practitioner, update your NPPES record.

STC*A8:562:82—Invalid rendering provider relationship. Verify that the rendering provider NPI is present. Rendering provider is required for taxonomy codes multi-specialty—193200000X and single specialty —193400000X.

STC*A7:562:82—Verify the rendering provider NPI is valid. If valid, verify it is active on NPPES.

*Please note, claims may have previously pended and processed (including payment).