guides:claim-rules:rendering-provider-swap
Table of Contents
Rendering Provider Swap
Automatically replace a rendering provider's NPI and name on claims when a specific NPI is found.
Applies to: Professional (837P), Dental (837D)
When to Use This
- A provider has left your practice and claims still come in with their old NPI
- A locum tenens provider is filling in and you need their claims billed under a different NPI
- A provider's NPI was entered incorrectly in the source system and you need to correct it
- A payer requires a specific rendering NPI for certain states
Fields
| Field | Required | Description |
|---|---|---|
| Start Date | Yes | When this rule becomes active |
| End Date | No | When this rule expires. Leave blank for no expiration |
| Payer Number | No | Only apply this swap for a specific payer. Leave blank to apply for all payers |
| Subscriber State | No | Only apply when the subscriber's state matches (2-letter code, e.g., TX). Leave blank for all states |
| Original NPI | Yes | The NPI to look for on the claim's rendering provider |
| Replacement NPI | Yes | The new NPI to put on the claim |
| Entity Type | Yes | Person (individual provider) or Organization |
| Replacement Last Name | Yes | The new provider's last name (or organization name) |
| Replacement First Name | No | The new provider's first name (leave blank for organizations) |
| Taxonomy Code | No | If set, also updates the rendering provider's taxonomy code |
| Notes | No | Your reference notes — why this rule exists, who requested it |
Examples
Example 1: Provider Left Practice
Dr. Smith (NPI 1234567890) has left your practice. All claims should now show Dr. Jones (NPI 9876543210) as the rendering provider.
| Field | Value |
|---|---|
| Original NPI | 1234567890 |
| Replacement NPI | 9876543210 |
| Entity Type | Person |
| Replacement Last Name | JONES |
| Replacement First Name | SARAH |
| Start Date | 04/01/2026 |
Example 2: Payer-Specific NPI for Texas
Aetna (payer 60054) requires a different rendering NPI for Texas claims.
| Field | Value |
|---|---|
| Payer Number | 60054 |
| Subscriber State | TX |
| Original NPI | 1234567890 |
| Replacement NPI | 5555555555 |
| Entity Type | Person |
| Replacement Last Name | SMITH |
| Replacement First Name | JOHN |
| Taxonomy Code | 207Q00000X |
What Happens on the Claim
When a claim is processed and the rendering provider NPI matches:
- The NPI in Loop 2310B (Rendering Provider) NM1 segment is replaced
- The provider name is updated
- If a taxonomy code is specified, the PRV segment is updated
- A note is added to the claim: “Swapped rendering provider NPI {old} to {new}”
- The change appears in the claim's Applied Validation Modules as “RenderingProviderSwapModule”
guides/claim-rules/rendering-provider-swap.txt · Last modified: by brad.sharp