Change Request Detail
Type of Request
Professional Claim (HCFA 1500)
DSMO Process Completed
Business Reason
The 5010 ASC X12 837 Professional TR3 does not support identifying both a locum tenens provider and the provider for whom he/she is substituting services.  Medicare needs to identify both on a claim in accordance with Medicare law and because of fraud associated with the faiiure to identify both providers on a claim.
Medicare recommends that there be a separate Locum Tenens Provider Loop; allow the Rendering Provider Loop to be for the original provider in a locum tenens situation.   Although the TR3 indicates that the locum tenens provider be identified in the Rendering Provider Loop, doing so results in there being no place to identify the original provider for whom the locum tenens provider is substituting.  The Billing Provider Loop might work in instances where the billing provider is an individual, but it fails when the billing provider is a group practice, and there is no way to reliably identify the individual for whom the locum tenens provider was substituting.
DSMO Category
Approved.  The DSMO supports the business reason for identifying both providers and recommends that the technical solution be determined by X12.
Appeal Recommendation