Creation of Internal Vendor Provider Files (Rev. 866, 07-03-06) - Competitive Acquisition Program

by  Jared Staheli
July 9th, 2015

The designated carrier shall create an internal provider file for each vendor which includes the names, addresses, and UPINs, (NPI when effective), of those physicians who have elected that vendor.

The designated carrier shall edit incoming vendor claims to verify that the UPIN number on the claim for the ordering physician is one of the UPINs on the provider file for that vendor. The designated carrier shall treat the claim as unprocessable when it receives claims from vendors with ordering physician UPINs that do not match a physician UPIN on the provider file and return the following messages:

Remittance Advice Messages:

Reason Code 96 - Non-covered charge(s).

Remark Code: N265 – Missing/incomplete/invalid ordering provider primary identifier.

Medicare Summary Notice Messages:

17.11 This item or service can not be paid as billed.

and

9.7 – We have asked your provider/supplier to resubmit the claim with the missing or correct information.

Spanish:

17.11 -Este servicio no se puede pagar según facturado.

and

9.7 - Le hemos pedido a su proveedor que envíe la reclamación con la información omitida o incorrecta.

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 17