The 5010 837P TR3 (pg 262) states that Rendering Provider is “Required when the Rendering Provider data information is different than that carried in Loop ID-2010AA – Billing Provider.” Is this difference based on either name or NPI, or must both be different?
We compare the NPIs of the Rendering and Billing Provider in accordance with our validation software. We have been approached by our (re-pricing client) to possibly reconsider how we determine same vs. different for these two provider data loops. There are a number of instances where the Billing Provider may be a group w/ the same NPI as the individual Rendering Provider.
Since not all providers in a group are necessarily considered ‘in-network’, our re-pricing client is unable to properly calculate payment of the correct allowance when the Billing Provider is a group and no Rendering Provider is sent in the 2310B Loop because the two data loops (2010AA and 2310B) appear to be the “same” due to like NPIs.
The situational rule for 2310B/NM1 states "Required when the Rendering Provider Information is different than that carried in Loop ID-2010AA Billing Provider. If not required by this implementation guide, do not send."
Therefore, if the rendering provider information, which is inclusive of the NPI and provider taxonomy, is the same as the billing provider, and the 2310B information is submitted, this does not comply with the TR3.