Unfortunately, the payer only mentioned the word provider in this rejection without defining if they are talking about the billing provider, the rendering provider, or the referring provider. Below, we will try to give you tips as to most common problems they may be pointing to, but if that does not work, it may be time to get on the phone with the payer to find out why they might be rejecting.
IMPORTANT: When calling the payer, make sure to let them know that the claim was EDI rejected. Usually, when you call, the first person you talk to is in the payers adjudication department. These people can only see claims that made it past EDI (were not EDI rejected). You may ask to talk to their EDI department or whoever handles EDI rejections. They will have a record of the rejection.
What they might be referring to
Luckily, there are only a few provider ID's that might go on a claim form. You may want to check the following to see if they are valid before you take the time to call the payer.
- Rendering NPI - Under Providers in Therabill, make sure the NPI that you have entered for the rendering provider is valid. Also, sometimes payers require that you enroll each of your rendering NPI under your billing NPI with them (this is rare, but known to happen). In this case, they could be saying that they do not have the rendering NPI registered.
- Billing NPI - Make sure the billing NPI that you are submitting to them (equivalent to Box 33A of the CMS-1500, typically what you have entered under Admin in Therabill) is the same NPI that the payer knows you by. It could be that they are not able to find your NPI in their database of registered billing providers.
- Referring Provider NPI: If you are submitting a claim to them that has a referring provider (Box 17 of the CMS-1500), make sure the NPI is valid.