====== Billing Provider Override ======

Override the billing provider on claims based on payer, subscriber state, rendering provider, CPT codes, place of service, or claim type. Optionally override the pay-to provider as well.

**Applies to:** Professional (837P), Institutional (837I), Dental (837D)

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===== When to Use This =====

  * A payer requires claims billed under a specific group NPI instead of the individual provider
  * Multi-state practices need different billing entities per state
  * A payer requires a different billing address or tax ID
  * You need a different pay-to provider for payment routing
  * A specific rendering provider's claims should bill under a different entity

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===== Fields =====

==== Filter Conditions ====

^ Field ^ Required ^ Description ^
| Start Date | Yes | When this rule becomes active |
| End Date | No | When this rule expires |
| Payer Number | Yes | Which payer triggers this override |
| Subscriber State | No | Only apply when subscriber is in this state (2-letter code). Blank = all states |
| Rendering Provider NPI | No | Only apply when this rendering NPI is on the claim |
| Place of Service | No | Only apply when the claim's POS matches (2-digit code) |
| Claim Type | No | Professional, Institutional, or Dental. "Any" applies to all |
| CPT Codes | No | Comma-separated CPT codes. Only apply if claim contains one of these codes. Blank = all |

==== Billing Provider (what to change to) ====

^ Field ^ Required ^ Description ^
| Billing NPI | Yes | The new billing provider NPI |
| Entity Type | Yes | **Person** or **Organization** |
| Billing Name | Yes | Organization name or last name |
| Billing First Name | No | First name (for individual providers) |
| Address 1 | No | Street address. Leave blank to keep existing |
| Address 2 | No | Suite, floor, etc. |
| City | No | City |
| State | No | 2-letter state code |
| Zip | No | Zip code |
| Tax ID | No | EIN or SSN for the billing entity |

==== Pay-To Provider (optional) ====

If you need payments sent to a different address than the billing provider, fill in these fields. Leave all blank to skip pay-to override.

^ Field ^ Required ^ Description ^
| Pay-To NPI | No | NPI for the pay-to entity (filling this in activates pay-to override) |
| Pay-To Name | No | Organization name |
| Pay-To Address | No | Street address |
| Pay-To City/State/Zip | No | Pay-to address |

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===== Examples =====

=== Example 1: Bill Under Group NPI for Aetna ===

All Aetna claims should bill under the group entity instead of individual providers.

^ Field ^ Value ^
| Payer Number | 60054 |
| Billing NPI | 9876543210 |
| Entity Type | Organization |
| Billing Name | TEXAS MEDICAL GROUP LLC |
| Address 1 | 500 COMMERCE ST |
| City | DALLAS |
| State | TX |
| Zip | 75201 |
| Tax ID | 751234567 |

=== Example 2: State-Specific Billing for BCBS ===

BCBS claims where the subscriber is in New York need a different billing entity.

^ Field ^ Value ^
| Payer Number | 00621 |
| Subscriber State | NY |
| Billing NPI | 1111111111 |
| Entity Type | Organization |
| Billing Name | NORTHEAST MEDICAL GROUP |

=== Example 3: Rendering-Specific Override ===

When Dr. Smith is the rendering provider on Medicare claims, bill under the supervising physician's group.

^ Field ^ Value ^
| Payer Number | 00882 |
| Rendering Provider NPI | 1234567890 |
| Billing NPI | 5555555555 |
| Entity Type | Person |
| Billing Name | JOHNSON |
| Billing First Name | MICHAEL |

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===== What Happens on the Claim =====

When all filter conditions match:

  - Loop 2010AA (Billing Provider) is updated: NPI, name, entity type
  - If address fields are provided, N3 (address) and N4 (city/state/zip) segments are updated
  - If Tax ID is provided, the REF*EI segment is updated
  - If Pay-To NPI is set, Loop 2010AB (Pay-To Provider) is created or updated
  - A note is added: "Changed the billing provider"
  - Shows in Applied Validation Modules as "BillingProviderOverrideModule"

**Important:** If multiple rules match the same claim, they apply in order — the last match wins since it overwrites the previous changes.

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