Last Modified: 4/1/2020
Location: FL, PR, USVI
Business: Part B
Q: I purchased a portion of a diagnostic test. When I complete the claim, where and how do I indicate this information?
A: If you purchased the technical component (TC) or interpretation (PC) of certain diagnostic tests from a separate entity that does not share a practice location with the billing provider, submit a separate claim for the anti-markup (purchased) service.
• Click here
to determine if the billing arrangement of the diagnostic service is subject to anti-markup payment limitations.
Claims for anti-markup services should be completed in the same manner as a standard claim. Below are instructions for areas of particular attention when completing anti-markup service claims.
Paper claim instructions
1. If submitting an anti-markup service on a CMS-1500 paper claim form, mark "Yes" in Item 20 and enter the purchase amount and indicate the national provider identifier (NPI) of the performing entity in Item 19.
• Note: Claims will be returned as unprocessable if:
• Item 20 has "Yes" marked with no dollar amount.
• Item 20 has "No" marked with a dollar amount.
• Item 20 has a dollar amount, but "Yes/No" is not marked.
2. Enter the name and address of the location where the service was physically rendered in the Service Facility Location Information area (paper claim form Item 32) and indicate the NPI of the performing entity who actually rendered the service in the Service Facility Location ID area (Item 32a of the paper form).
• Reminder for paper claim submitters: Only one address can be billed per claim; do not include the PC on a claim with a purchased TC or vice versa. Failure to submit a separate paper claim for each component will result in your claim being returned as unprocessable.
Electronic claim instructions
1. Complete the 837P 2400 loop (Purchased service information), segments PS101 [Purchased service provider identifier] indicating the NPI of the entity who actually rendered the service and PS102 [Purchased service charge amount] indicating the amount you paid to the performing entity for the service.
• Example: PS1*1234567890*57.35
2. Complete the 837P 2310C loop with the name and address of the entity's location where the purchased service was physically rendered as it would typically be completed. Indicate the NPI of the provider from whom the services were purchased in the Service facility location ID area (2310C Facility Primary Identifier loop, segments NM108 [XX] and NM109 [NPI].
3. Additionally, complete the Purchased Service Provider Information area by entering the entity's information from whom the services were purchased in the 837P 2420B loop, segments NM101, NM102, NM108, NM109, for all anti-markup services.
• NM101 = Entity identifier code (enter 'QB' in this field)
• NM102 = Entity type qualifier (person='1'; non-person/facility='2')
• NM108 = Identification code qualifier (XX)
• NM109 = Purchased service provider identifier (NPI)
Points to remember for all anti-markup services: An NPI is required on all anti-markup service claims.
• Do not complete Item 32b (electronic loop 2310C, segment REF02). If any information is entered, your claim will be rejected or returned as unprocessable.
• If an NPI is missing, invalid, or submitted in the wrong area (e.g., valid NPI submitted in Item 32b or electronic loop 2310C, segment REF02), the claim will be returned as unprocessable.
• Note: Effective on or after April 1, 2015, billing physicians and suppliers are required to report the name, address, ZIP code, and NPI of the performing physician or supplier when the performing physician or supplier is enrolled in a different contractor’s jurisdiction. Physicians and other suppliers will no longer be permitted to submit their own NPI in Item 32a (or its electronic equivalent) when the performing physician or supplier is located in another jurisdiction.
• Example 1 (Puerto Rico): If a San Juan provider purchases a service performed by a provider in San Sebastian, the San Sebastian provider's address and NPI should be reported.
• Example 2 (Florida): If a Jacksonville, Florida provider purchases a diagnostic service from a mobile provider located in Kingsland, Georgia, they would report the physical location and NPI of the provider where services were performed (Kingsland, GA).
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