5010 – Billing to Medicare DME Carriers Article Keywords: EDI, DMERC, Medicare, DME, 5010, responsible provider

Symptoms: Responsible providers need to be set up to send claims to Medicare DME for ANSI 5010. Claims may be rejected with messages similar to the following: R^^Category: Acknowledgement/Rejected for Invalid Information The Claim/Encounter has invalid information as specified in the Status details and has been rejected Status: Entity's National Provider Identifier (NPI) Entity: Rendering Provider^^^.

Problem Description: In ANSI 5010, the rendering provider information should no longer be included in electronic claim files sent to Medicare DME carriers. The easiest way to meet this new requirement is to set up a billing identification row under the Responsible Provider to file as an individual (as opposed to part of a group) and to use the group NPI as opposed to provider’s individual NPI. This will populate loop 2010AA NM109 (the billing provider NPI) with the group NPI, and will leave the rendering provider loop (2310B) out of the claim file as required by Medicare DME carriers.

Resolution: To set up the responsible provider to bill to Medicare DME with the group NPI and no rendering NPI, please complete the following steps: 1. Go to Administration, click Edit and select Responsible Providers.

5010 – Billing to Medicare DME Carriers 2. Click the magnifying glass to bring up a list of Responsible Providers.

3. Double-click the first provider that files claims to Medicare DME to modify the record (or single-click the provider and click Edit).

5010 – Billing to Medicare DME Carriers 4. Click the Billing Identification tab. 5. If there is already a row created for your Medicare DME insurance carrier, double-click to modify it. If there is not already a row created for the Medicare DME carrier, click New to create a new row.

6. If creating a new row, click the radio button to the left of Insurance Carrier and select the Medicare DME carrier in the field provided. 7. In the File Claims As area of the window, select the radio button for Individual. 8. Set the Additional ID 1, NPI and Federal Tax ID fields to pull From Company. All other fields can be left blank.

5010 – Billing to Medicare DME Carriers 9. Click OK. Click OK. 10. Repeat steps 3-8 for each responsible provider filing claims to Medicare DME.

Please note: Each procedure on each DME claim requires an Ordering Provider be set on the Charge(2) tab of the procedure. If the Responsible Providers are used as the Ordering Providers on DME procedures, the Group NPI will be sent in the Ordering Provider loop of the claim file, which may cause the claim to be rejected. In order to prevent this rejection, we recommend setting up each Responsible Provider in the Referring Provider table, and using that instance of the provider as the Ordering Provider on the DME procedures. For more information on adding the Ordering Provider to procedures on DME visits, please refer to the following article: Adding Ordering Provider to DME Procedures (5010) To add the Responsible Providers to the Referring Provider table for use as Ordering Providers, please complete the following steps: 1. In Administration, click Edit and select Referring Providers. 2. Search for one of the Ordering Providers to verify that an instance has not already been created in the Referring Providers table. If the provider is found, double-click to modify the record. If not, click New. 3. Enter the provider's name in the fields provided and press the Tab key on the keyboard to populate the List Name field. 4. Add -ORDERING to the end of the List Name to indicate that this instance of the provider should be used as the Ordering Provider. 5. Enter the provider's Organization and Address in the fields provided. 6. Enter the provider's individual NPI in the NPI field. Please note: For the purposes of this article, all other fields are optional. The ID field will populate automatically when the record is saved. Please do not set, change or remove the value in the ID field manually. 7. Click OK to save the record.

5010 – Billing to Medicare DME Carriers

8. Repeat steps 2-7 for each Responsible Provider that might be used as the Ordering Provider on DME claims. Healthco Information Systems Support Services KB https://hiskb.healthcois.com/KnowledgebaseArticle10370.aspx