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New TRICARE East Region Billing/Rendering EDI Provider Edits

WPS Military and Veterans Health is preparing to make changes to our EDI front-end editing for TRICARE East Region 837 Professional claims. Currently, many claims pend within the claims processing system because they were submitted with an incorrect Billing Provider Name and/or National Provider Identifier (NPI), or the rendering provider segment is missing when a clinic submitted the claim.

To allow our trading partners time to implement changes, WPS will be providing notices until an implementation date has been determined for the new edits. WPS will be using the National Plan and Provider Enumeration System (NPPES) as the resource for validating NPI data, therefore it is important that provider’s review their NPPES records for accuracy.

The following edits will be applied to 837 Professional claims only:

  1. When a Billing NPI is submitted in NM109 of the 2010AA Billing Provider Loop:
    • If the NPI submitted is a Type 1, then the Sole Proprietor field must be a Yes.
    • If the NPI submitted is a Type 2, then the Rendering Provider Segment must be submitted in Loop 2310B or 2420A.

    • Note: The Rendering Provider NPI will not be required at this time, but the segment must be provided with the Rendering Provider Name.

  2. As a reminder, the Billing Provider Address Loop 2010 must have a physical address, and if the services rendered were not at this address, then the Service Facility Loop 2310C must be submitted. If there is more than one Service Facility for the claim, then use the Service Facility Loop 2420C.

You will be notified again when WPS has determined a formal implementation date for these Billing/Rendering provider changes.

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