EmblemHealth Guide for NPIs and Taxonomy Codes

Health care is a data-driven industry. We need your correct data on file and need it correctly documented on your claims to be able to pay you correctly and to provide your patients with all the benefits they are entitled to. 

National Provider Identifiers (NPIs) and taxonomy codes are two key pieces of data that inform reimbursement and benefit access. Government programs, such as the Medicaid, HARP, and Child Health Plus programs, mandate health plans to submit rendering and billing providers’ NPIs and taxonomy codes as a condition of payment for the services. The Centers for Medicare & Medicaid Services (CMS) has required pharmacies to deny drugs to members if their prescribing provider does not have the appropriate taxonomy code on file. 

This guide defines what these codes are, how to obtain them, and how to use them on your claims and/or encounter data submissions. 

TIP: Ask your practice management system vendor to ensure your software is capturing and correctly populating your NPIs and taxonomy codes in your electronic claims submissions. 

Questions?
If you or your system vendor has any questions regarding the above EmblemHealth 837 NPI technical requirements, please contact an EmblemHealth Electronic Media Claims (EMC) Technical Representative at EMC@Emblemhealth.com.

HIPAA Transaction Companion Guides
We have made available transaction-specific companion guides to the ASC X12N implementation guides adopted under the Health Insurance Portability and Accountability Act (HIPAA). They contain specifications for electronic transmission to EmblemHealth.

Part I: National Provider Identifiers (NPIs)

Tip to Avoid Rework: EmblemHealth rejects claims if the NPI is not correctly populated in 837 electronic claims transactions. Make sure your NPI is entered correctly the first time.

Introduction
Federal law mandates that health care practitioners use their unique, 10-digit NPI when submitting standard electronic health care transactions, such as claims. Compliance with HIPAA requires the use of ANSI ASC X12N (Version 5010) transaction standards and implementation guides for electronic health care transactions. For full instructions on submitting electronic claims, see the EmblemHealth Guide for Electronic Claims Submissions.

NPIs on Paper Claims Submissions

NPI Requirements for Professional Claims on CMS 1500 Form

  • Referring Provider: Box 17b 
  • Rendering Provider: Box 24J 
  • Service Facility Location: Box 32a 
  • Billing Provider: Box 33a

NPI Requirements for Institutional Claims on UB-04 Form

  • Billing Provider: Box 56
  • Attending Provider: Box 76
  • Operating Provider: Box 77
  • Other Provider: Boxes 78 and 79

NPIs on EDI Claims Submissions

NPI Requirements for Professional Provider Claims (837P)

  • Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
  • Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.
  • Rendering Provider 2310B: Only required when the Rendering Provider information is different from the information carried in Billing Provider Loop 2010AA. If this claim-level loop is sent, an NPI is required.
  • Rendering Provider 2420A: Only required when the Rendering Provider information is different from the information carried in the 2310B or 2010AA loops. If this line-level loop is sent, an NPI is required.

NPI Requirements for Institutional Claims (837I)

  • Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
  • Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.
  • Attending Provider 2310A: Only required when the Attending Provider information is different from the information carried in the 2310A or 2010AA loops. If this loop is sent, an NPI is required.

NPI Requirements for Dental Provider Claims (837D)

  • Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
  • Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.
  • Rendering Provider 2310B: Only required when the Rendering Provider information is different from the information carried in Billing Provider loop 2010AA. If this loop is sent, an NPI is required.

Part II: Taxonomy Codes

Important: Please register taxonomy codes for all specialties on the National Plan and Provider Enumeration System (NPPES) and provide all taxonomy codes noted in the table below on all EmblemHealth claims and/or encounter data submissions. Taxonomy codes are required on Medicaid claims as indicated below. If not included on an electronic submission, the claim will reject as an unclean claim. You will have an opportunity to resubmit with the missing taxonomy code(s). Paper claims will be denied for missing information. You can resubmit the claim with the missing information following our processes for resubmitted paper claims.

While Commercial and Medicare claims will not be rejected or denied for missing taxonomy code(s), we ask that you submit them on all claims to facilitate claims pricing.

Introduction
Taxonomy codes identify the provider’s type, classification, and area of specialization. Each taxonomy code is a unique, 10-character alphanumeric code that enables providers (individuals and organizations) to identify their specialty at the claim/encounter level. 

A provider can have more than one taxonomy code, due to training, board certifications, licenses, 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/encounters. This will assist EmblemHealth in more accurate and timely processing of claims/encounters. 

You can view the Healthcare Provider Taxonomy Code Set

Impact to Drug Prescriptions
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. 

ESI follows New York prescriptive authority logic, which compares the drugs being prescribed with a prescriber’s taxonomy in the NPPES. 

TIP: 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.


Taxonomy Codes on Electronic Claims and Encounter Data Submissions

Professional
Taxonomy codes on electronic claim submissions with the ASC X12N 837P format are placed in below-listed data elements in respective Segment and Loop.

Level

Loop Segment Data Element Data Element Data Element
Billing Provider 2000A PRV PRV01 = BI PRV02 = PXC PRV03 – Taxonomy Code

Rendering Provider – Claim Level

2310B PRV PRV01 = PE PRV02 = PXC PRV03 – Taxonomy Code
Rendering Provider – Line Level 2420A PRV PRV01 = PE PRV02 = PXC PRV03 – Taxonomy Code


Dual specialty providers (have multiple specialties or practicing both as PCPs and specialists) are asked to include the taxonomy (specialty) code for the specialty in which they provided services. By including the taxonomy qualifier and value in Loop 2000A, segment PRV03; Loop 2310B, segment PRV03; or Loop 2420A, segment PRV03, we can determine the specialty for which services were provided or to determine the correct copayment to deduct for the following places of service:

  • POS 11 – Office
  • POS 12 – Home
  • POS 22 – Outpatient department of a hospital

Institutional
Taxonomy codes on electronic claim submissions with the ASC X12N 837I format are placed in below-listed data elements in respective Segment and Loop.

Level Loop Segment Data Element Data Element Data Element
Billing Provider 2000A PRV PRV01 = BI PRV02 = PXC PRV03 – Taxonomy Code
Attending Provider Claim Level 2310A PRV PRV01 = AT PRV02 = PXC PRV03 – Taxonomy Code


Taxonomy Codes on Paper Claims Submissions

Professional
For paper CMS-1500 professional claims, the taxonomy code should be identified as shown in the table below.

Dual specialty providers (have multiple specialties or practicing both as PCPs and specialists) are asked to include the taxonomy (specialty) code for the specialty in which they provided services. By including the taxonomy qualifier and value on the CMS 1500 form in columns 24I and 24J, we can determine the specialty for which services were provided or to determine the correct copayment to deduct for the following places of service:

  • POS 11 – Office
  • POS 12 – Home
  • POS 22 – Outpatient department of a hospital

Institutional

For paper UB-04 institutional claims, the taxonomy code should be identified as shown in the table below.

 

 

Information Required in Claims and Encounter Data Submission
Institutional Claims & Encounter Data
Provider data element Inclusion condition EDI location Paper claim location
Billing Provider Taxonomy Code Always include billing provider taxonomy code 2000A PRV01, 02, 03 81
Attending Provider Taxonomy Code Always include attending provider taxonomy code 2310B PRV01, 02, 03 76
Professional Claims & Encounter Data
Provider data element Inclusion condition EDI location Paper claim location
Billing Provider Taxonomy Code Always include billing provider taxonomy code 2000A PRV01, 02, 03 33b – enter taxonomy code along with prefix/qualifier ‘ZZ’
Rendering Provider Taxonomy Code (claim level) Always include either the rendering provider taxonomy code (claim level) or rendering provider taxonomy code (service level) 2310B PRV01, 02, 03 Enter the taxonomy code in box 19 preceded by qualifier ‘REF ZZ’
Rendering Provider Taxonomy Code (service level) Always include either the rendering provider taxonomy code (claim level) or rendering provider taxonomy code (service level) 2420A PRV01, 02, 03 24J – enter taxonomy code preceded by qualifier ‘ZZ’ in box 24i

For full instructions on electronic claims submissions, see EmblemHealth Guide for Electronic Claims Submissions.

Part III: Obtaining an NPI and Registering All Taxonomy Codes

Taxonomy codes registered with the NPPES at the time of NPI application are reflected on the NPPES confirmation notice along with the assigned NPI number.

Current taxonomy codes registered, including any subsequent changes, may be obtained on an inquiry basis by visiting the NPI Registry website

The taxonomy code(s) you have on file with NPPES must be consistent with the Medicare Provider/Supplier to Healthcare Provider Taxonomy Code Set to facilitate your ability to prescribe medications. ESI, our pharmacy vendor, will deny prescriptions if they are not appropriate to your taxonomy code(s) on record.

What You Need to Do to Avoid Prescription Denials

  • Review the Medicare taxonomy crosswalk to see which taxonomies are eligible to prescribe
    • 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.
    • Click on Find Your Taxonomy Code in the left navigation.
    • Scroll to View the complete data set.
  • Update your taxonomy code(s), if necessary.
    • Go to npiregistry.cms.hhs.gov.
    • Enter your NPI number in the 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 user ID 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.

Tip: Avoid General Codes

We strongly encourage physicians, nurses with advanced practice degrees, 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
  • Registered Nurse – instead, select a taxonomy code that reflects your advanced practice nursing degree

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