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)
| 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 |
| 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 |
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 |
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 |
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 |
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 |
When all filter conditions match:
Important: If multiple rules match the same claim, they apply in order — the last match wins since it overwrites the previous changes.