Table of Contents
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)
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
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 |
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 |
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.