Facilities in a Health System

Facilities in a Health System: SummaCare Explained

If you are a facility in a Health System and your checks are issued to the Parent Company, you should use the NPI number specifically assigned to your facility. If you use another facility’s NPI number under the Parent Company, it will result in the check being issued correctly to the Parent Company, however, the Explanation of Payment (EOP) or the 835 Health Care Payment Advice will indicate the incorrect facility. An example follows:

XYZ Skilled Nursing is part of ABC Health System, which uses the NPI Number of the system. If the 837 Health Care Claim Institutional is submitted with the incorrect NPI, which is assigned to New Ambulatory Center in the same system, the payment will be issued to the ABC Health System, but the EOP or 835 Health Care Payment Advice will list New Ambulatory Center as the servicing facility.

If you are a facility in a Health System and your checks are issued to the individual facility, please use the NPI number assigned to you specifically. If you use another facility’s NPI number, the claim will be processed erroneously. The EOP or 835 Health Care Payment Advice will be issued to the facility associated with the RNPI that was submitted. An example follows:

ABC Skilled Nursing has its own NP! Number. New Ambulatory Center has its own NP! Number. !f ABC Skilled Nursing submits a claim using the NP! number assigned to New Ambulatory Center. The EOP or 835 Health Care Payment Advice will be returned to New Ambulatory Center along with the payment.

Submitters should be careful to use the member’s identification number as it appears on their SummaCare member ID card. If the member’s identification number is not submitted, the claim may be rejected or denied. Each member of the family is listed on the member identification card. Make sure the name of the patient is the same as the name on the identification card.

To learn more about EDI and become a certified EDI Professional please visit our course schedule page.

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