Wiki Payor hierarchy order reviewed on a claim

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drewbart@sbcglobal.net

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Hi,
Can someone share the hierarchy order in which payor systems review claims with regards to tax ID, taxonomy. We are seeing many inclusive related denials and I am trying to understand the order in which a claim is reviewed by payors. Is it 1. Billing provider NPI, tax ID and taxonomy 2. Service Provider NPI, taxonomy

I believe that some of our inclusive denials are really an issue of the taxonomies bumping each other. Some providers taxonomies are not reflective of the true specialty charge. ( IE. A general surgeon who also works a critical care/Trauma specialty bills 99291, claim is sent with GS taxonomy)

I appreciate any information someone can share. Thank you! :)
 
I think it depends on the credentialing of the provider and the particular payer. Some only look at group TIN or group NPI where others look at subspecialty taxonomy. Often I have seen where providers think they are credentialed as one subspecialty but really their credentialing was not what they thought. You would have to check and see how each is credentialed and what the payer policy is.
 
I agree with @amyjph that it's basically up to the particular payor. I will add that Medicare 2 digit specialty codes are far fewer than taxonomy codes. For example, in taxonomy codes, there may be a subspecialty of surgery of the hand, but there are far fewer Medicare specialty codes and that may or may not be considered a different specialty than orthopedics by a payor.
 
Thank you very much for pointing me to credentialing and payor policy as I believe that is where the answers are. I also appreciate the specialty code comment and I'm not quite sure how that is communicated to a payor on the electronic claim. There are some taxonomies that have more than 1 specialty code. I'm thinking it must be with licensing and contracting? Thank you again!
 
It's with credentialing. The provider can only have one, primary taxonomy. You would want to talk with your credentialing person and/or you can look it up on the NPI search. Again, not all payers care about this, they look at TIN or Group NPI. Throwing NPPs into this mix can also impact claims processing.

NPPES NPI Registry

npiregistry.cms.hhs.gov npiregistry.cms.hhs.gov

Find Your Taxonomy Code | CMS

Learn how to find your taxonomy code, and how to access the taxonomy code data set. A taxonomy code is a unique 10-character code that designates your classification and specialization. You will use this code when applying for a National Provider Identifier, commonly referred to as an NPI.
www.cms.gov www.cms.gov
Note: You may select more than one code or code description when applying for an NPI, but you must indicate one of them as the primary code.
 
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