HipaaMagic Provider Lookups:

Billing and Pay to Provider: All billing and pay to provider loops are filled with data from the NSF file first and overwritten with data from the provider lookup tables if the Slam It radio button is checked. The key field for lookup is the BA0_02 field in the NSF file. The BA0_02 field is the first field on the Provider table form from the Data menu. In the first page tab, upper left, and when the mouse is placed on it you see a tool tip that says BA0_02. The billing provider entry in the Provider table should have the billing provider specialty code filled in as well as the group or practice employer's tax ID, with a 24 qualifier. The Contact field and the Contact Phone Number are also required. Use no punctuation in the phone number.

Rendering Provider: Claim Level or 2310B loop. The first detail service line in the NSF is searched for the existence of either FA0_23 or FB1_14 or FB1_17. These fields in the NSF are Rendering Provider NPI, Rendering Provider Last Name or Company Name and Rendering Provider UPIN, respectively. If you don't have any of these fields then you do not get a rendering provider loop in the ANSI file at either the claim level or the detail level, 2310B or 2420A loops. 

If you have one or more of the FA0_23, FB1_14 or FB1_17 fields we will try to find the provider in the provider table as follows: First, we will use the FA0_23, rendering provider NPI field to look up the provider in the provider table. This is the Provider Medicare ID in the Provider table. It is on the second page of the provider maintenance form under the Billing Provider ID's tab. Remember FA0_23 = Medicare ID in Provider table. None of the other ID numbers in the table are used in this search.

Second, if the FA0_23 field is blank we will use the FB1_17 rendering provider UPIN number to search the provider table. This is the Provider UPIN in the provider table. It is on the second page frame of the provider maintenance form under the Billing Provider ID's tab. Remember FB1_17 = Provider UPIN ID in Provider table. None of the other ID numbers in the table are used in this search.

Once the correct provider record is found, the NM1 segment and any applicable ref segments are filled in, in the ANSI file.

If there are subsequent entries in the rendering provider fields on detail records other than the first detail record, FA0 sequence 02 or higher, they will be used and included in the ANSI file only if they are different than the first detail record.

Referring provider: Claim level 2310A loop. For the claim level referring provider we look first in the EA0_21 field for a UPIN number and then in the EA0_20 for the referring provider NPI or Medicare ID. The Provider table is searched using the Provider UPIN as the key field or the Provider Medicare ID in the event that the first search is unsuccessful. If there is no entry in the EA0 record for referring provider we will use the entry in the first detail line or FA0 record to apply to the entire claim. If there are subsequent entries in the detail records for referring provider, they will be included in the ANSI output file only if they are different than the first detail record entry.

Referring Provider: Detail level 2420F loop. For the detail level referring provider we use the FA0_24 field first and then the FB1_13 field second to search for the provider record in the provider table. If there is an FA0_24 entry and we get a hit on the provider table using the Medicare ID as the key field we will then ignore the FB1_13 information if we have the Referring Provider radio button checked and Slam It checked also.

Empire Medical Review Services, Inc
11357 North Port Washington Road
Phone: 262.240.9700
Mequon, Wisconsin 53092