Set Rendering Provider Name And NPI To

Certain payers mandate that the Practice Billing Entity details or facility information appear on a CMS-1500 form instead of the actual rendering provider. This can be achieved by setting up a claim line item rule that guides the system on when and how to display this information.

Workflow

Let's review how to add the rendering provider information using a claim line item rule!

1. Navigate to Management Center > Claim Rules.
   
    
2. Click Create Claim Line Item Rule.
   
3. Select the Practice.
   
4. Next, give the rule a name.
5. Update the Claim Type to Professional.
   
6. Then click the box next to each desired condition to create criteria that a claim should meet before the rule applies.
   
7. Next, under Behaviors, click Set Rendering Provider Name and NPI to:.
8. And update the drop-down to one of the following options:
   • Facility: This option will use both the name and NPI referenced in the facility's profile.
   • Practice Billing Entity: This option uses the practice's name and NPI referenced in the Practice Admin > Insurance Billing section of the RCM.
   • Rendering Provider: This option uses the actual rendering provider name and the NPI selected when recording the service.
     
      
9. Click Save to complete the process.
    

Box Number(s)

• UB-04: n/a
• CMS-1500: Box 24j - Rendering Provider

Frequently Asked Questions and Helpful Hints

Let's review some helpful hints and some more commonly asked questions!

Frequently Asked Questions

• The best way to determine if a scheduled change set is appropriate is to gauge how many claims will be affected. For example, if you want the rule to apply to previously billed claims as well as new claims going forward, create the rule without a scheduled change set. 
  
  However, if you want the rule to apply only to newly created claims, use a scheduled change set to instruct the system to look only for claims with dates of service on or after the set date. For more information on scheduled change sets, click here.
• If you are creating the rule to apply to previously billed claims, navigate to the Patient > Treatment Episode > Claims > Review Corrections section and click Check For Corrections. If corrections are generated, follow the process outlined here to complete the process. If no claims are flagged for rejection, click here to troubleshoot the rule why the rule may not be applying.

Helpful Hints

If one of your conditions is payer-based, select any applicable Current Sequence options instead of the Primary Behavioral Payer. This will ensure the rule applies to secondary and tertiary claims when needed. To read more about how to set claim rule conditions and order, see the Claim Rule: Setting Claim Rule Conditions article.