EDI 5010 Documentation 837 Professional - Loop 2010AA Billing Provider

2010AA Billing Provider
        
Although the name of this loop/segment is “Billing Provider” the loop/segment really identifies the billing entity. The billing Entity does not have to be a health care provider to use this loop.This loop information is same as CMS 1500 Form Box No 33 and Box No 25 as you can see below picture.

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Before going to detail, I recommend to understand the Concept of NPI, Provider billing with Individual NPI and Provider Billing with Group NPI.  Please refer this URL for better understanding or download this document.
The following things should be available in the PMS application to handle this loop correctly.
  • In the Provider profile, there should be option to specify whether claims for this provider should go as “Bill with Individual NPI” or Bill with Group NPI.
  • Some times provider may register with insurance company via SSN or Tax ID. So this option should be part of the Provider profile.
  • Optionally, you can have override option for the above two by insurance, by location.


    • You can see an     example here from in one of my PMS Application.
    The NM1 segment reports the organizational name of the Billing Entity.   The first part of this segment is the Entity ID code.  The Billing Provider Entity ID code is 85.  The next element is the Entity Type Qualifier.  The Entity Type Qualifier will be a 1 if the entity is setup as a Person and 2 if the Entity Type is set up as a Non Person.  The Next Part of the segment is the Name of the Entity.  If the Entity is a person it will report the last name, first name and middle name.

    Billing Entity is Practice
    If the practice is enrolled with the insurance company under the practice name then claims need to be sent with the Practice Name as the billing entity. 
    Example:  Dr. Robert Jones is enrolled at Medicare under the name of his practice Jones Chiropractic.  Medicare will want to see Jones Chiropractic in Loop 2010AA NM1 segment.  They will want the name of the doctor to report in Loop 2310B NM1 segment.

    Billing Entity is Provider If the provider is enrolled with the Insurance Company under the provider’s name alone then the provider’s name needs to be sent in Loop 2010AA NM1 segment. 
    Example: Dr. Jones is enrolled at Aetna under his name Robert J Jones. Aetna will want Robert J Jones to report in Loop 2010AA NM1 segment.

    Now let’s start the detail implementation.

    Loop Seg ID Segment Name Format Length Ref# Req Value
    2010AA NM1 Billing Provider Name ID 3 R NM1
    Element Separator AN 1 *
    NM101 Entity Identifier Code ID 2/3 98 R 85
    Element Separator AN 1 *
    NM102 Entity Type qualifier ID 1/1 1065 R See below for more information
    Element Separator AN 1 *
    NM103 Name Last or Organization Name AN 1/60 1035 R See below for more information
    Element Separator AN 1 *
    NM104 Name First AN 1/35 1036 S See Below for more information
    Element Separator AN 1 *
    NM105 Name Middle AN 1/25 1037 S See Below for more information
    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 See below for more information
    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 Print NPI Number. See below for more information
    Segment Terminator ~
                   
    NM102 - Entity Type Qualifier
    Code qualifying the type of entity
    Code Definition
    1 Person
    2 Non-Person Entity
    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then print the value as 2.
    If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then print the value as 1.

    NM103 – Name Last or Organization Name
    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then print the value from the Practice Information (i.e) Practice Name.
    If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then print the value from the Provider information (i.e) Provider Last Name.

    NM104 – Name First

    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then DO NOT PRINT ANY VALUE.
    If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then print the value from the Provider information (i.e) Provider First Name.

    NM105 – Name Middle
    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then DO NOT PRINT ANY VALUE.
    If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then print the value from the Provider information (i.e) Provider Middle Name.

    NM107 – Name Suffix

    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then DO NOT PRINT ANY VALUE.
    If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then print the value from the Provider information (i.e) Provider Suffix.

    NM109 – Identification Code
    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then take the Practice NPI (Group NPI) from the Practice Information.
    If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then print the value from the Provider information (i.e) Provider NPI.
    2010AA Billing Provider Address

    According to HIPAA 5010, a Loop 2010AA Billing Provider Address must not contain the following exact phrases: “Post Office Box”, “P.O. BOX”, “PO BOX”, “LOCK BOX”, “LOCK BIN” or “P O BOX”. The Loop 2010AA Billing Provider Address must be a physical address. This rule applies to dental, professional, and institutional claims. But the paper 1500 form is not subject to HIPAA compliance restrictions.

    Now let’s start the detail implementation.

    Loop Seg ID Segment Name Format Length Ref# Req Value
    2010AA N3 Billing Provider Address AN 2 R N3
    Element Separator AN 1 *
    N301 Address Line 1 AN 1/55 166 R See below for more information
    Element Separator AN 1 *
    N302 Address Line 2 AN 1/55 1065 S See below for more information
    Segment Terminator ~

    N301 – Address Line 1
    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then print the value from the Practice Information (i.e) Practice Address
    If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then print the value from the Provider information (i.e) Provider Address 2.

    N302 – Address Line 2
    This is optional. Print only if data available.
    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then print the value from     the Practice Information (i.e) Practice Address 2 if available
    If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then print the value from the Provider information (i.e) Provider Address 2 if available.

    2010AA Billing Provider City/State/Zip code
    In the version 5010A1 format, a change has been made to include the full 9-digit ZIP Code for the Billing Provider (2010AA loop for ANSI claims). Providing all zeros in the 4-digit extension will cause front end rejections.The best practice is to capture the 9-digit ZIP code in the practice management system.

     
    Loop Seg ID Segment Name Format Length Ref# Req Value
    2010AA N4 Billing Provider City / State / Zip Code AN 2 R N4
    Element Separator AN 1 *
    N401 City Name AN 2/30 19 R See below for more information
    Element Separator AN 1 *
    N402 State or Province Code ID 2/2 156 R See below for more information
    Element Separator AN 1 *
    N403 Postal Code ID 3/15 116 R See below for more information
    Segment Terminator ~

    N401 , N402 , N403

    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then print the value from
    the Practice Information (i.e) Practice City/State/Zip code.If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then print the value from the Provider information (i.e) Provider City/State/Zip code.



    2010AA Billing Provider – Sample
    Test data
    Field Value
    Practice Name XYZ Practice
    Practice Address 1 6623 REACH BLVD
    Practice Address 2 APT E10
    Practice City Brooklyn
    Practice State NY
    Practice Zip code 112304444
    Practice NPI or Group NPI 8585858585
    Provider First Name Smith
    Provider Middle Name K
    Provider Last Name Sean
    Provider Address 1 5537 KINGS HIGHWAY
    Provider Address 2 APT 6G
    Provider City Frisco City
    Provider State NY
    Provider Zip Code 112348888
    Provider NPI Number 6565656565
     

    Use case 1 :

    If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then the following will be printed.
    NM1*85*2*XYZ Practice*****XX*8585858585~
    N3*6623 REACH BLVD*APT E10~
    N4*Brooklyn*NY*11230-4444~

    Use case : 2
    If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then the following will be printed.

    NM1*85*1*Sean*Smith*K***XX*6565656565~
    N3*5537 KINGS HIGHWAY*APT 6G~
    N4*Frisco City*NY*11234-8888~


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