When it comes to processing claims, many patients don't know that the provider billing information means everything when it comes to paying the claim correctly. This little section of information can mean the difference between processing your claim in network or out of network.
First, let me give you a quick background on the evolution of provider billing information. Years ago, providers were issued a number as an individual provider called a UPIN. Additionally, they would have a group number to identify them with each practice, and then they would have an individual and group number with each separate insurance. Of course, each group practice had a Tax Identification Number.
Then the government said all of this needed to be simplified and the answer was the NPI or National Provider Identifier. This was to replace all other numbers for a provider, except of course the Tax Id.
You would think with this concept that insurance companies could process a claim and find a provider with just the NPI, right? Nothing could be further from the truth! Instead of relying on just the NPI to process a claim, insurance companies have added additional edits in their system to make sure they're paying the right provider.
For instance, when a claim arrives in the insurance company's system the NPI may be matched first but then the next edit will be to look at other pieces of information such as the way the provider's practice or street address is spelled. If these aren't exact matches, the claim is kicked out for manual processing.
The next step is for an individual to review the claim and match it in their system. This will depend on how the provider's information is listed in what their looking at. In most cases, the provider's information is listed in a pull down menu format so that the processor has to scroll through the list. If they're in a hurry, they're not going to scroll long!
If you have issues with your claims processing out of network in error and you're sure that your provider is in network, it's a good idea to ask about the provider billing section of the claim. Ask the provider exactly what was sent in that field on the claim. Then ask the insurance company exactly what they received in the same field. These two simple questions may help you get your claims issue resolved much quicker.