Friday, 14 September 2012

EDI 5010 Documentation 837 Professional - Loop 2310A Referring Provider Name

2310A Referring Provider
        

In this loop, all the information will be taken from  Referring Provider Master.
Take a look of our sample screen here how referring provider information are stored in the system.

image
 
Very important Note:
It is something funny. Sometime some payer will not accept without 2310A referring provider information even though if the patient is not referred by any provider. In that case, payer will ask to put the rendering provider information same as in the referring provider information loop.  I am not sure , still this rule exists. So we handle this in the insurance master setup screen by saying “Use Rendering provider information as Referring Provider information if claim does not have any referring provider”. If this option is selected, then if there is no actual referring provider in the claim, then we will just write the same information as of rendering provider in the 2310A Loop.
 

Now let’s start the detail implementation.
Loop Seg ID Segment Name Format Length Ref# Req Value
2010BA NM1 Referring Provider Name ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R DN
Element Separator AN 1 *
NM102 Entity Type qualifier ID 1/1 1065 R 1
Element Separator AN 1 *
NM103 Name Last or Organization Name AN 1/60 1035 R Referring Provider Last Name
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S Referring Provider First Name
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S Referring Provider Middle Name
Element Separator AN 1 *
NM106 Name Prefix AN 1/10 1038 Not used
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S Referring Provider Suffix
Element Separator AN 1 *
NM108 Identification code Qualifier ID 1/2 66 R XX
Element Separator AN 1 *
NM109 Identification code AN 2/80 67 R Referring Provider NPI Number
Segment Terminator ~
               
 
NM102 - Entity Type Qualifier
Code qualifying the type of entity
Code Definition
1 Person
 
 2310A Referring Provider Secondary Identification
 
Loop Seg ID Segment Name Format Length Ref# Req Value
2310A REF Referring Provider Secondary Identification ID 3 R REF
Element Separator AN 1 *
REF01 Reference identification ID 2/3 128 R See below for more information
Element Separator AN 1 *
REF02 Reference identification AN 1/50 127 R Print the Reference number
Segment Terminator ~
 
 

REF01 -  Reference Identification Qualifier

Code qualifying the type of Reference
Code Definition
0B State License Number
1G Provider UPIN Number
G2 Provider Commercial Number
 
2310A Referring Provider  - Examples
 
Now let us some examples on this Loop
Assume that claim contains a referring Provider who’s Last Name is John and First Name is Smith and there is no Middle Name. And also there is no NPI and secondary identification Number.
NM1*DN*1*John*Smith****~

Now add a middle Name for the above Referring Provider such as ‘ms’
NM1*DN*1*John*Smith*ms***~

Now add NPI Number for the above Referring Provider such as 1234567890
NM1*DN*1*John*Smith*ms***XX*1234567890~

Now add a secondary identification number such as “1G - Provider UPIN Number” and let the number be “UPIN999” (Note; Secondary identification is next line)

NM1*DN*1*John*Smith*ms***XX*1234567890~
REF*1G*UPIN999~

 
Another Example with element structure.
NM1*DN*1*SOLOMON*ROBERT****XX*1902825870~
 
image
 
        

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com.

5 comments:

  1. Hi Sentil. About your Very Important note. I agree with your solution of making the referring provider equal to the rendering provider by default. Here is my understanding of why some payers demand a "referring provider," even though it is not a true referral situation. What they are really demanding is an ordering provider for a diagnostic, such as a lab or x-ray. An ordering provider can be added to a service line, but if there is none there, the ordering provider is assumed to be the referring provider. We see this with United Healthcare.

    ReplyDelete
    Replies
    1. I have been approached by a client who says certain payers don't require a referring to be sent. thus, they are being denied because the NM1*DN....etc...still appear. has anyone else experienced this and have a solution?

      Delete
  2. Hey Senthil, I guess there is one typo on a table below "very important note". loop name is 2010BA instead of 2310A.
    by the way, awesome work! There are bits and pieces everywhere on 837P and 837I but not structured documentation. Thank you for sharing your work.

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