Author Topic: in network rendering provider/out of network facility  (Read 1483 times)

jrnmthc

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in network rendering provider/out of network facility
« on: February 04, 2016, 12:46:56 PM »
Hi if a new rendering provider is in network, but the facility (npi and tax id) has always been out of network.  How will be the claims be processed?  In network or out of network?  Thanks for your help.

RichardP

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Re: in network rendering provider/out of network facility
« Reply #1 on: February 05, 2016, 12:26:45 AM »
The in-network or out-of-network distinction is always tied to who gets paid.  And who gets paid is always the billing entity.

So - in your situation - who is the billing entity?  Whose NPI Number is being submitted to the Insurance Carriers in Box 33a of the CMS 1500 form?

Since your provider joined something, I assume that the facility is the billing entity, with its own NPI Number and EIN.  I assume that the facility bills, with its own NPI Number, the insurance carriers pay the facility, and the facility pays the provider for the work s/he does.

If your provider is the billing entity, and his NPI Number is placed into Box 33a of the CMS 1500 form, then the insurance carriers will be paying your provider according to whatever participating provider agreement is in effect.

jrnmthc

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Re: in network rendering provider/out of network facility
« Reply #2 on: February 05, 2016, 09:11:36 AM »
what about box 25.  is that the facility tax id, or the provider.  We would want the checks to be made payable to the facility not the provider. ugh sorry, this is getting confusing.

RichardP

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Re: in network rendering provider/out of network facility
« Reply #3 on: February 05, 2016, 02:54:54 PM »
ugh sorry, this is getting confusing.

No it is not.

The in-network or out-of-network distinction is always tied to who gets paid.  And who gets paid is always the billing entity.

Everything on the CMS 1500 Form belongs to the billing entity.  That is what the form is for.  Billing.  By the billing entity.

The only thing that goes on the CMS 1500 form that does not belong to the billing entity would be Box 14J (who did the work) and Box 17 (Referring Provider) - primarily for Medicare billing, but also for any other carrier that requires it.  Both Box 14J and Box 17 require the Type 1 NPI Number of the licensed person who actually did the work or made the referral.  If unlicensed folks did the work, then the Type 1 NPI Number of the supervising authority would go there.

The Tax ID Number for Box 25 should be the ID Number of the billing entity.  If the facility is the billing entity, the facility's Tax ID Number would go inBox 25 of the CMS 1500 form.

Michele

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Re: in network rendering provider/out of network facility
« Reply #4 on: February 06, 2016, 07:42:14 PM »

The only thing that goes on the CMS 1500 form that does not belong to the billing entity would be Box 14J (who did the work) and Box 17 (Referring Provider) - primarily for Medicare billing, but also for any other carrier that requires it.  Both Box 14J and Box 17 require the Type 1 NPI Number of the licensed person who actually did the work or made the referral.  If unlicensed folks did the work, then the Type 1 NPI Number of the supervising authority would go there.

The Tax ID Number for Box 25 should be the ID Number of the billing entity.  If the facility is the billing entity, the facility's Tax ID Number would go inBox 25 of the CMS 1500 form.

I think RichardP meant to type 24J, not 14J.  Rendering provider NPI goes in 24J.  ;)
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RichardP

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Re: in network rendering provider/out of network facility
« Reply #5 on: February 08, 2016, 06:51:32 PM »
Thank you Michele. :)