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.

 

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 1
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. You can hire me as consultant for EMR/PMS Domain and Web development on EMR/PMS Product!