Determining the Service Location for Outpatient Services

A frequent issue among those working with HealthChoices data is accurately identifying the specific location where outpatient services are rendered, especially when the provider delivering care has more than one service location. The difficulty stems from the differing requirements for identifying providers in HIPAA EDI transactions vs. the PA DHS MIS, PROMISe™, as well as the different formats employed for reporting claims information in HIPAA EDI transactions vs. PROMISe™.

Identifying Providers in HIPAA EDI Transactions
Under the HIPAA Administrative Simplification Rule, health care providers are required to submit electronic claims for payment as encounters using a standardized format. This is commonly referred to as Electronic Data Interchange, or EDI. Healthcare claims are to be submitted in 837 format; 837 Institutional (837 I) transactions to bill claims for care delivered by hospitals and skilled nursing facility locations, and 837 Professional (837 P) transactions to bill claims for care delivered by physicians, suppliers and other non-institutional providers at both outpatient and inpatient facility locations. 1(An outpatient service may be delivered in a facility setting or a non-facility setting. A facility is a hospital, skilled nursing facility (SNF) or ambulatory surgery center (ASC). A non-facility is an outpatient setting like a clinician’s office or outpatient clinic. For services that can be billed as either facility or non-facility, payments are lower when billed as facility-based vs. non-facility-based service.)

Another requirement of the Administrative Simplification Rule is that all providers have a standard number to identify themselves on healthcare transactions; the National Provider Identifier (NPI). The NPI is a ten-digit “intelligence free” number, which means that it does not carry any other information about a provider other than their identification.

Information about the kind of care a provider offers is communicated in Taxonomy codes. A Taxonomy code is a unique ten-character alphanumeric code. Each code has three distinct levels: Level I = provider type, Level II = classification, and Level III = area of specialization that enables a provider to identify the care they are qualified to deliver. Taxonomy codes can be assigned at either an individual provider or at an organization level. A provider can register for any Taxonomy code(s) they wish.

While the goal of the Administrative Simplification Rule was to establish common standards and identifiers to simplify the exchange of information, its implementation has at times complicated the identification of a provider’s service location. There are several reasons for this ambiguity. One reason is that there are no standard rules regarding the number of NPIs for which a provider may apply. Some providers have only one NPI, but many office locations. For these providers, the specific service location cannot be derived solely from their NPI. Another reason is that there is no logical connection between a provider’s Taxonomy codes and their service locations.

Also, while the HIPAA 837 P transaction layout always requires the billing provider be reported on the encounter for outpatient services, the rendering provider information is not always required. 2(The 837 Implementation Guide states that the Rendering Provider loop is “situational” and is not a “syntactically required loop”. However, the loop is “required when the Rendering Provider information is different than that carried in either the Billing Provider or the Pay-to-Provider loops.) For HealthChoices BH encounters, if the rendering provider is not reported, it is assumed to be the same as the billing provider.

Further complicating the recording of provider information on HIPAA 837 P transactions is that the information is recorded in different sections, or “loops”, on the encounter layout. All billing provider information is recorded in one loop; 2010AA. When the rendering provider is present, its NPI and taxonomy code are recorded in loop 2310A; however, the service location is recorded in a different loop; 2310C – Service Facility Location Secondary Information.

Identifying Providers in PROMISe™
In PROMISe™, providers are identified by their Master Provider Index (MPI), which is comprised of a nine-digit number for the provider parent organization + four-digit number for the provider service location. Each thirteen-digit MPI is associated with a single address, so a provider with multiple offices will have a distinct MPI for each location. Providers are required to enroll every service location where they provide services to Medicaid recipients in order to receive reimbursement for services rendered there. PA DHS recently reiterated this requirement in bulletin 99-18-11.

When a provider enrolls with PA DHS, each MPI is mapped to the provider’s NPI and nine-digit zip code. If more than one MPI service location falls within the same nine-digit zip code for a given NPI, for example if a provider enrolls under more than one provider type at the same location, PA DHS distinguishes among the locations using the different Taxonomy codes associated with the NPI.

Although PA DHS uses Taxonomy codes to distinguish among the locations associated with a provider’s NPI, they do not use Taxonomy codes to describe the type of care a provider offers. Instead, PA DHS uses combinations of Provider Type and Specialty. Providers may enroll under one or more Provider Type and Specialty combination, depending on the type of care they provide.

Unfortunately, there is not a 1:1 relationship between a Taxonomy code and a combination of Provider Type and Specialty, but rather each combination of Provider Type and Specialty can map to more than one Taxonomy code, as shown here.

Provider Type
Provider Specialty
11Mental Health /Substance Abuse110Psychiatric Outpatient251K00000X Agencies Public Health or Welfare
11Mental Health /Substance Abuse110Psychiatric Outpatient251S00000XAgencies Community Behavioral Health
11Mental Health /Substance Abuse110Psychiatric Outpatient261Q00000XAmbulatory Health Care Facilities
11Mental Health /Substance Abuse110Psychiatric Outpatient261QM0801XAmbulatory Health Care Facilities
Mental Health (including community Mental Health Center)
11Mental Health /Substance Abuse110Psychiatric Outpatient261QM0850XAmbulatory Health Care Facilities
Adult Mental Health
11Mental Health /Substance Abuse110Psychiatric Outpatient261QM0855XAmbulatory Health Care Facilities
Adolescent and Children Mental Health

The Claims Life Cycle
To understand how these different provider identifiers, claims formats and requirements affect the accuracy of deriving a service location, it’s useful to review the basic life cycle of Medicaid electronic claims filing:

    1. The provider submits an electronic claim to the insurer, typically in HIPAA EDI 837 HealthCare claims format
    2. The insurer adjudicates the claim and translates it, if needed, to meet the particular requirements of the state MIS
    3. The 837 encounter is submitted for adjudication to the state MIS

Pennsylvania has idiosyncratic processing requirements related to provider identification which must be satisfied for 837 encounters to be successfully adjudicated. Specifically, PROMISe™ requires a valid rendering provider MPI, rather than the NPI, which is the identifier mandated by HIPAA EDI format on 837 encounters.

The simplest way to comply with the PROMISe™ requirement would be for the insurer (in this case the Behavioral Health Managed Care Organizations or BH-MCOs) to require providers to include the 13-digit MPI of the rendering provider on each 837 service line. Since each 13-digit MPI is associated with only one address, there would be no ambiguity about service location. However, HIPAA EDI format does not mandate the inclusion of the rendering provider MPI on claims; therefore, payers cannot impose this requirement on providers.

It is therefore up to the BH-MCO to either derive the rendering provider MPI from the information on the claim, or submit the claim without deriving the MPI, in which case it will be derived in PROMISe™ during adjudication, using the crosswalk PA DHS has established to derive MPIs on incoming Fee-for-Service (FFS) claims.

The Crosswalk between NPI and MPI
To facilitate the MPI derivation process for BH-MCOs, DHS provides a crosswalk between 13-digit MPIs and data elements that can be required on an 837 claim under HIPAA:

  • NPI;
  • Taxonomy code; and
  • 9-digit zip code.
  • In theory, it should be possible for the BH-MCO to derive the correct MPI from those elements, and therefore identify the exact service location. In practice, however, this process often imposes unreasonable demands on the submitter. Consider the provider shown, Marsha Brown. 3(Provider identifiers and demographics have been de-identified.)

    Prov Type
    NameZip CodeAddressCity
    8153663010103T00000XBehavioral Health and Social Service Providers 518301403000619PsychologistBROWN,
    009158341106 CHURCH STGREENWAY
    8153663010103T02000XCognitive & Behavioral518301403000419PsychologistBROWN,
    009158341108 CHURCH STGREENWAY
    8153663010103T00000XBehavioral Health and Social Service Providers 518301403000519PsychologistBROWN,
    8153663010103T00000XBehavioral Health and Social Service Providers 518301403000319PsychologistBROWN,
    0091585323405 ROSE LANEOAKVIEW
    8153663010103T00000XBehavioral Health and Social Service Providers 518301403000119PsychologistBROWN,
    0091585361627 JACKSON DROAKVIEW
    8153663010103T00000XBehavioral Health and Social Service Providers 518301403000219PsychologistBROWN,
    009167013404 W 28TH STMANSFIELD

    Suppose the billing provider sends Marsha Brown’s NPI as the rendering provider identifier. There are several possible service locations from which to choose when crosswalking the rendering provider on the encounter submitted by the provider to a rendering provider MPI at a service location on the encounter submitted to PROMISe™. To determine the service location on the encounter for submission to PROMISe ™, the insurer would presumably look to the service facility location address on the 837 submitted by the provider. But, even if the service location is present, mapping to the correct rendering provider MPI could still poses challenges for several reasons:

      1. Address matching is complicated by the fact that there are different ways an address may be represented (e.g. 404 W 28th St, 404 West 28th St., 404 E. 28th Street, etc.);
      2. The nine-digit zip code provides a less ambiguous element on which to match – but in the case of Marsha Brown, there are two different locations that share the same nine-digit zip code
      3. There are likely some claims that contain inexact, incomplete or incorrect service facility information

    Suppose the billing provider sent the correct 9-digit zip code for the service location, but it happens to map to the zip code for the two rendering provider MPIs in Greenway. The insurer could use the PROMISe™ strategy for distinguishing among locations sharing a common zip code, but this would require the billing provider to use two different (arbitrary) Taxonomy codes to distinguish between the 106 Church Street and 108 Church Street locations.

    Changes on the Horizon
    Potential changes to both the HIPAA EDI standards and PROMISe™ MIS are on the horizon. The American National Standards Institute (ANSI) is in the process of developing the next version of EDI standards, 7030™. According to the public review and comment schedule posted by X12, which is the organization chartered by ANSI to develop EDI standards, a second public review of 837 transaction standards is pending. And, the PROMISe™ system is slated for replacement by the end of 2020 with a new system, currently begin referred to as the MMIS 2020 Platform. Whether or not the standards and system changes will bring more clarity to the process of determining the service location for outpatient services, though, remains to be seen.