Out of Network Denials

[JVentura1]

Hi Everyone,

Our claims are being processed as out of network for one carrier, even though we have a contract.  On the electronic file at the carrier they are saying the service site is blank and then it looks at the billing address.  A few months ago I had to change the billing address because we moved.  All that changed was the City and State.  The Legal Name is the same. 

Does the Insurance look at the first  12 to 15 in the service site first, if the system does not recognize this it goes to the Billing Information.  If the Service Site is the same is that way it is left blank. 

Our EDI Carrier has a rule that if the rendering provider name has to be striped at the clearing house and replace it with the Group NPI.  The legal name has a dba.

So confused.

[Rclausing]

If you have an assigned provider representative with the carrier, they can sort this out for you. Otherwise, it seems most likely that you need to find out who you can send a W-9 to so that they can update their database.  Claims are processed by a computer that might kick out a claim for any incorrect information fields (or data that doesn't match what is in their database). For instance if they have one address in a data field, and you are submitting a different one, yes that would most likely cause a claim to be kicked out.

"Our EDI Carrier has a rule that if the rendering provider name has to be striped at the clearing house and replace it with the Group NPI.  The legal name has a dba."

Apologies, but I am not quite certain what you mean here. Are you saying your PM software is set up to enter the rendering physicians name in a field, but your clearing house requires an NPI? And that this is the cause of your OON claims? If so, this is an issue you need to take up with either the practice management software vendor, or the clearing house.

[PMRNC]

It sounds like you have something not matching up, you do indeed want to do a W9, you want to make sure all of your info MATCHES exactly!!! IRS/NPI, etc.. must be same and all match up. I had a big mess because a provider's street address was misspelled.