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  • Claims > Taxonomy Codes: Definition and Claims Use

    Taxonomy codes are administrative codes set for identifying the practitioner type and area of specialization for health care practitioners. Each taxonomy code is a unique ten character alphanumeric code that enables practitioners to identify their specialty at the claim level. Taxonomy codes are assigned at both the individual practitioner and organizational practitioner level.

    Taxonomy codes have three distinct levels: Level I is the practitioner type, Level II is Classification, and Level III is the Area of Specialization. A complete list of taxonomy codes can be found within the Health Insurance Portability and Accountability Act (HIPAA).

    Taxonomy codes are self-reported, both by registering with the National Plan and Provider Enumeration System (NPPES) and by electronic and paper claims submission.

    Taxonomy Codes registered with NPPES at the time of NPI application are reflected on the confirmation notice document received from NPPES with the provider’s assigned NPI number. Current taxonomy codes registered, including any subsequent changes, may be obtained on an inquiry basis by visiting the NPI Registry website

    A practitioner can have more than one taxonomy code, due to training, board certifications etc. It is critical to register all applicable taxonomy codes with NPPES and to use the correct taxonomy code to represent the specific specialty when filing claims. This will assist EmblemHealth in more accurate and timely processing of claims. 

    Please provide Taxonomy codes on all EmblemHealth claims, the absence of these codes may result in incorrect payment.

    Taxonomy codes on electronic claim submissions with the ASC X12N 837P and 837I format are placed in segment PRV03 and loop 2000A for the billing level and segment PRV03 and loop 2420A for the rendering level. For paper CMS-1500 professional claims, the taxonomy code should be identified with the qualifier “ZZ” in the shaded portion of box 24i. The taxonomy code should be placed in the shaded portion of box 24j for the rendering level and in box 33b preceded with the “ZZ” qualifier for the billing level.

    The Importance of Accurate Taxonomy Codes

    Taxonomy codes are administrative codes that identify your provider type and area of specialization. It is a unique ten character alphanumeric code that enables you to identify your specialty at the claim level. We want to make sure you know how this will affect you and your EmblemHealth patients.

    What is happening
    Starting on September 11, 2018, if your taxonomy code is invalid or your taxonomy indicates you do not have the right to prescribe certain drugs, pharmacies using Express Scripts, Inc. (ESI)—our primary pharmacy network—will not fill your patients’ prescriptions, even if it is a refill of a previous prescription.

    Why this is happening
    Express Scripts, Inc. is following New York prescriptive authority logic, which compares the drugs being prescribed with a prescriber’s taxonomy in the National Plan and Provider Enumeration System (NPPES).

    To avoid getting calls from upset patients and multiple pharmacies, update your taxonomy codes. Don’t let your patients get turned away at the pharmacy.

    What you need to do

    • Review the Medicare taxonomy crosswalk to see which taxonomies are eligible to prescribe.
      • Go to cms.gov and search “Crosswalk Medicare Provider/Supplier to Healthcare Provider Taxonomy.”
    • Update your taxonomy code(s), if necessary.
      • Go to npiregistry.cms.hhs.gov.
      • Enter your National Provider Identifier (NPI) in the National Plan and Provider Enumeration System (NPPES).
      • Click on the NPI number. Scroll to the bottom of the record to see your taxonomies.
      • If the taxonomy is not a valid CMS taxonomy, go to nppes.cm.hhs.gov/#/. Enter your username and password in the individual NPI portion of the site and update the taxonomy code as needed. Please make sure you select a taxonomy that belongs to an individual provider, not an entity.

    Refer to the example below to learn more about how to make sure your taxonomy code accurately reflects what you do. For more information:

    • Go to cms.gov.
    • Click on the Medicare tab at the top of the page.
    • Scroll to the Provider Enrollment & Certification section.
    • Click on Medicare Provider-Supplier Enrollment.
    • Scroll to the bottom.
    • Click on Taxonomy in the left navigation.

    Tip for Selecting the Correct Taxonomy Code

    Avoid General Codes

    We strongly encourage physicians and other prescribers to avoid choosing the very general taxonomy codes below. They may inappropriately identify the prescriber as someone who cannot write prescriptions for patients, resulting in a rejected prescription.

    • Specialist
    • Contractor
    • Hospital
    • Clinic

    Individuals should avoid choosing a taxonomy that represents a facility. Instead, select the taxonomy for your actual specialty.

    For Nurses

    If you are a nurse and have an advanced practice degree, we urge you to avoid selecting “Registered Nurse” as a taxonomy for the same reason stated above. Your taxonomy code should reflect that you have an advanced practice nursing degree to ensure accurate identification of what you do and to avoid unnecessary rejects.

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    Glossary terms found on this page:

    A process by which a physician who has been tested for proficiency in a medical specialty or subspecialty, by a medical specialty board, has passed those tests and been certified as proficient in that medical specialty.

    A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    The government agency responsible for administering the Medicare and Medicaid programs.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    A business entity that performs delegated functions on behalf of the insurer or managed care organization.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    A federal act that protects people who change jobs, are self-employed or have pre-existing medical conditions. The act standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those offered to employees in large group plans. The act also contains provisions to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status and protects the confidentiality of protected health information of members. Also known as HIPAA.

    A federal act that protects people who change jobs, are self-employed or have pre-existing medical conditions. The act standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those offered to employees in large group plans. The act also contains provisions to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status and protects the confidentiality of protected health information of members. Also known as the Health Insurance Portability and Accountability Act.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

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