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Provider matching

Suggest edit Updated on August 31, 2021

The Provider Validation module manages 2 levels of matching and validation during claims adjudication. First, SCE must determine that each provider and/or practitioner instance identified on the claim matches to the provider and practitioner instances identified in the system’s source of truth.

This entails the matching of certain key criteria (e.g. name and NPI) which is described in greater detail below. Second, SCE must also validate the relationship between the provider and/or practitioner and the Business entity represented on the claim.

Every provider or practitioner must be associated to a Business entity to ensure the correct adjudication of a claim. The association of a practitioner or provider to a Business entity links the Tax Identification Number (TIN) and servicing address of the billing provider to the provider or practitioner who is rendering the service. The relationship between the provider or practitioner and the Business entity is shown below.

The workflow shown below illustrates the end-to-end process followed during the execution of the Provider Eligibility module.

Provider data model

There are multiple pages that are used to provide information for the provider match, validations, and contract selection. These pages will need to be populated for the SCE to perform the necessary lookups and validations.

PageUsage
D_CE_ES_ProviderPickUsed by elastic search to look up the providers.
D_LoadProviderByNPIUsed to load the provider information based on the Provider NPI
D_CE_BillingProviderListUsed to look up business entity from a list
D_CE_FetchBusinessEntitiesUsed by elastic search to identify the business entity
D_CE_BusinessEntityUsed to get information on the business entity based on the Tax ID and effective date
D_CE_PlanDetailsUsed to look up information on the plan for validation checks and processing
D_CE_ProviderContractUsed to lookup the provider contract for validation checks and processing
Validating providers

The Provider Eligibility module compares the provider data from the source of truth to the provider data found on the claim. This capability is applied to each provider found on the claim, and applies the same matching criteria to all providers encountered, which includes National Provider Identifier (NPI), first name and last name, with the exception of the Business entity (or billing provider) for which it considers tax identification number, name, and address.

The SCE utilizes a reusable ES query that assigns a weight of “1” to each search criterion to indicate that SCE is looking for an exact match for each specific property. If an exact match for each property is met, SCE then declares the provider on the claim to be a valid match to the provider in the source of truth. In the instance that an exact isn’t made, the SCE sets a “fuzzy match” criterion against the provider’s first and last name when the provider’s NPI (or TIN for billing provider) matches exactly. This enables an up-to-two-character mismatch for the provider’s first and/or last name to be submitted and still achieve a successful match.

The configuration for the validations of the Provider’s name, Taxonomy, NPI and address, is controlled by a decision table, ValidateProvidersMetadata.

This decision table enables configurations for:

  • The provider and level at which the matching logic will be applied (e.g., rendering provider – claim line)
  • The provider matching audit message displayed during claims adjudication
  • The event codes to be set during fallout for the following events
    1. Provider not found
    2. NPI length > 10
    3. Name mismatch
    4. Taxonomy mismatch
    5. Address mismatch
    6. NPI mismatch

Provider types can be considered for matching and validation during the execution of the provider eligibility module simply by either adding or removing the appropriate when conditions on each line from the decision table.

Set out of state indicators

The SCE assigns out of state indicators at the claim and line level when the servicing location (or billing address) differs from the state associated with the member on the claim. The SCE also assigns the servicing state on the claim and line to support other calculations. This is assigned, as the servicing state can be assumed from the billing provider in the absence of a servicing address on the claim.

Validate provider relationships

Once SCE declares (validates) that a match exists between the provider claim data and source of truth, SCE then validates the rendering provider’s relationship to the business entity identified on the claim. If there is a valid relationship existing between the rendering provider and the Business entity on the date of service, SCE then declares the association between the two valid. However, if the relationship is declared not to be valid on the date(s) of service, SCE sets an event code.

In addition, SCE determines whether the servicing address of the rendering provider is in effect on the date of service. If the servicing facility is associated to the servicing address on the claim on the date of service, SCE then declares the association between the rendering provider and the business entity to be valid.

Provider validation event codes

If there are missing providers or discrepancies, etc. between the information on the claim and the database, the event codes listed in the table below will set to the claim. Provider validation event codes will be set:

Event codeNameDescription
SPE-0002Billing provider not foundThe billing provider submitted on the claim does not match to any provider record stored in the system.
SPE-0003Billing provider name mismatchThe billing provider name submitted on the claim does not match the record stored in the system.
SPE-0004Billing provider address mismatchThe billing provider address submitted on the claim does not match the address stored in the system.
SPE-0005Billing provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the billing provider is not equal to 10 digits.
SPE-0006Billing provider taxonomy mismatchThe billing provider taxonomy submitted on the claim does not match the taxonomy stored in the system.
SPE-0007Billing provider NPI mismatchThe billing provider national provider identifier (NPI) submitted on the claim does not match the NPI stored in the system.
SPE-0008Referring provider NPI not foundThe referring provider NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0009Referring provider name mismatchThe referring provider name submitted on the claim does not match the record stored in the system.
SPE-0010Referring provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the referring provider is not equal to 10 digits.
SPE-0011Referring provider NPI not foundThe referring provider NPI submitted on the claim line does not match to any provider record stored in the system.
SPE-0012Referring provider name mismatchThe referring provider name submitted on the claim line does not match the record stored in the system.
SPE-0013Referring provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the claim line referring provider is not equal to 10 digits.
SPE-0014Rendering provider NPI not foundThe rendering provider NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0015Rendering provider name mismatchThe rendering provider name submitted on the claim does not match the record stored in the system.
SPE-0016Rendering provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the rendering provider is not equal to 10 digits.
SPE-0017Rendering provider taxonomy mismatchThe rendering provider taxonomy submitted on the claim does not match the taxonomy stored in the system.
SPE-0018Rendering provider NPI not foundThe rendering provider NPI for the claim line does not match to any provider record stored in the system.
SPE-0019Rendering provider name mismatchThe rendering provider name submitted on the claim line does not match the record stored in the system.
SPE-0020Rendering provider - Invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the claim line rendering provider is not equal to 10 digits.
SPE-0021Rendering provider taxonomy mismatchThe rendering provider taxonomy submitted on the claim line does not match the taxonomy stored in the system.
SPE-0024Pay-to provider address mismatchThe pay-to provider address submitted on the claim does not match the address stored in the system.
SPE-0025Attending provider NPI not foundThe attending provider NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0026Attending provider name mismatchThe attending provider name submitted on the claim does not match the record stored in the system.
SPE-0027Attending provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the attending provider is not equal to 10 digits.
SPE-0028Attending provider taxonomy mismatchThe rendering provider taxonomy submitted on the claim does not match the taxonomy stored in the system.
SPE-0029Operating provider NPI not foundThe operating provider NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0030Operating provider name mismatchThe operating provider name submitted on the claim does not match the record stored in the system.
SPE-0031Operating provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the operating provider is not equal to 10 digits.
SPE-0032Operating provider NPI not foundThe operating provider NPI for the claim line does not match to any provider record stored in the system.
SPE-0033Operating provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the claim line operating provider is not equal to 10 digits.
SPE-0034Other operating provider NPI not foundThe other operating provider NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0035Other operating provider name mismatchThe other operating provider last name submitted on the claim does not match the record stored in the system.
SPE-0036Other operating provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the other operating provider is not equal to 10 digits.
SPE-0037Other operating provider NPI not foundThe other operating provider NPI for the claim line does not match to any provider record stored in the system.
SPE-0038Other operating provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the claim line other operating provider is not equal to 10 digits.
SPE-0039Supervising provider NPI not foundThe supervising provider NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0040Supervising provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the supervising provider is not equal to 10 digits.
SPE-0041Supervising provider NPI not foundThe supervising provider NPI submitted on the claim line does not match to any provider record stored in the system.
SPE-0042Supervising provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the claim line supervising provider is not equal to 10 digits.
SPE-0043Service facility location not foundThe service facility location submitted on the claim does not match to any record stored in the system.
SPE-0046Service facility - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the service facility location is not equal to 10 digits.
SPE-0047Service facility location not foundThe service facility location submitted on the claim line does not match to any record stored in the system.
SPE-0048Service facility - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the claim line service facility location is not equal to 10 digits.
SPE-0049Purchased service provider NPI not foundThe purchased service provider NPI submitted on the claim line does not match to any record stored in the system.
SPE-0050Purchased service provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the claim line purchased service provider is not equal to 10 digits.
SPE-0051Ordering provider NPI not foundThe ordering provider NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0054Ordering provider - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the claim line ordering provider is not equal to 10 digits.
SPE-0055Assistant surgeon NPI not foundThe assistant surgeon NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0056Assistant surgeon name mismatchThe assistant surgeon name submitted on the claim does not match the record stored in the system.
SPE-0057Assistant surgeon - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the assistant surgeon is not equal to 10 digits.
SPE-0058Assistant surgeon taxonomy mismatchThe assistant surgeon taxonomy submitted on the claim does not match the taxonomy stored in the system.
SPE-0059Assistant surgeon NPI not foundThe assistant surgeon NPI for the claim line does not match to any provider record stored in the system.
SPE-0060Assistant surgeon name mismatchThe assistant surgeon name submitted on the claim line does not match the record stored in the system.
SPE-0061Assistant surgeon - invalid NPI lengthThe length of the submitted national provider identifier (NPI) for the claim line assistant surgeon is not equal to 10 digits.
SPE-0062Assistant surgeon taxonomy mismatchThe assistant surgeon taxonomy submitted on the claim line does not match the taxonomy stored in the system.
SPE-0065Invalid billing entity affiliationThe rendering provider for the claim line does not have a valid affiliation with the billing entity.
SPE-0066Referring provider taxonomy mismatchThe referring provider taxonomy submitted on the claim does not match the taxonomy stored in the system.
SPE-0080Service facility NPI not foundThe service facility NPI submitted on the claim does not match any record stored in the system.
SPE-0081Service facility NPI not foundThe service facility NPI submitted on the claim line does not match any record stored in the system.
SPE-0082Supervising provider name mismatchThe supervising provider name submitted on the claim does not match the record stored in the system.
SPE-0083Supervising provider name mismatchThe supervising provider name submitted on the claim line does not match the record stored in the system.
SPE-0085Ordering provider name mismatchThe ordering provider name submitted on the claim line does not match the record stored in the system.
SPE-0086Operating provider NPI not foundThe operating provider NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0087Other operating provider NPI not foundThe other operating provider NPI submitted on the claim does not match to any provider record stored in the system.
SPE-0089

Invalid affiliation

The service location reported on the claim line is not affiliated with the business entity indicated on the claim.
SPE-0090Billing provider not activeThe billing provider/business entity effective and/or end dates fall outside of the date of service on the claim line.
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