COT.002.113

BILLING-PROV-NPI-NUM

Data Element

DE Number

COT113

System DE Number

COT.002.113

File Name

COT - CLAIM OTHER

File Segment Number

COT00002

File Segment Name

CLAIM-HEADER-RECORD-OT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one.
Size	X(10)
FLF Start Position	727
FLF Stop Position	736
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When Type of Claim (COT.002.037) not in [3,C,W] then value must match Provider Identifier (PRV.002.081) 6. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization)

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-1541	If the billing provider NPI number is populated on a non-denied claim from an OT file, then the billing provider NPI number value reported must be a valid NPI number.
RULE-1542	If a claim is a non-denied claim from an OT file, then the billing provider NPI number value reported must be compatible with specified T-MSIS picture format: X(10).
RULE-1543	If the type of service is for a capitation payment to a HMO, HIO, PACE, PCCM, or PHP plan on a non-denied claim line from an OT file, then the BILLING-PROV-NPI-NUM value must not be populated.
RULE-1544	If a claim is a non-denied, non-void claim from an OT file, and the billing provider NPI number is populated, then for matching records in provider identifiers, the provider identifier type is equal to 2 (NPI).
RULE-7303	If a claim is a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion FFS, Medicaid or Medicaid-expansion CHIP Encounter, Separate CHIP FFS or Separate CHIP Encounter claim and is an original claim or a replacement/resubmission claim payment then either the billing provider NPI number or billing provider number must be populated.
RULE-7489	If a claim is a non-denied, non-void claim from an OT file and the billing provider NPI num is populated then claim header billing provider NPI num exists in the NPPES NPI data file.
RULE-7509	If a claim is a non-denied, non-void claim from an OT file and the billing provider NPI is populated and is a valid NPI in the NPPES file, then the 'entity type code' is equal to '2' (organization) or '1' (individual) in the NPPES NPI data file.
RULE-7766	If a claim is a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion CHIP Encounter or Separate CHIP Encounter claim and is an original claim or a replacement/resubmission claim payment then either the billing provider NPI number or billing provider number must be populated.
RULE-7826	If a claim is a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion CHIP Fee-for-service or Separate CHIP Fee-for-service claim and is an original claim or a replacement/resubmission claim payment then either the billing provider NPI number or billing provider number must be populated.
RULE-7907	If the billing provider NPI number is populated on a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion CHIP Encounter, or separate CHIP Encounter claim then the billing provider NPI number value reported must be a valid NPI number.
RULE-7911	If the billing provider NPI number is populated on a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion CHIP FFS, or separate CHIP FFS claim then the billing provider NPI number value reported must be a valid NPI number.

Measure ID	Measure Name
FFS-19-007-7	OT - Average # of PROV-LOCATION-ID per billing NPI
RULE-7911	% of claim headers with Billing Provider NPI Number in an invalid format
RULE-7907	% of claim headers with Billing Provider NPI Number in an invalid format
MCR-26-008-6	OT - Average # of unique combinations of PROV-LOCATION-ID and billing NPI per servicing NPI
MCR-26-005-5	OT - Average # of PROV-LOCATION-ID per billing NPI
MCR-26-002-4	OT - Average # of PROV-LOCATION-ID per beneficiary
MCR-23-009-7	OT - Average # of unique combinations of PROV-LOCATION-ID and billing NPI per servicing NPI
MCR-23-006-6	OT - Average # of PROV-LOCATION-ID per billing NPI
MCR-23-002-5	OT - Average # of PROV-LOCATION-ID per beneficiary
FFS-20-008-9	OT - Average # of unique combinations of PROV-LOCATION-ID and billing NPI per servicing NPI
FFS-20-005-5	OT - Average # of PROV-LOCATION-ID per billing NPI
FFS-20-002-2	OT - Average # of PROV-LOCATION-ID per beneficiary
FFS-19-009-9	OT - Average # of unique combinations of PROV-LOCATION-ID and billing NPI per servicing NPI
FFS-50-007-7	% of claim headers with Billing Provider NPI Number in an invalid format
FFS-19-004-5	OT - Average # of PROV-LOCATION-ID per beneficiary
FFS-18-010-10	OT - Average # of unique combinations of PROV-LOCATION-ID and billing NPI per servicing NPI
FFS-18-008-8	OT - Average # of PROV-LOCATION-ID per billing NPI
FFS-18-005-6	OT - Average # of PROV-LOCATION-ID per beneficiary
MIS-83-005-5	% missing: BILLING-PROV-NPI-NUM (COT00002)
MIS-25-005-5	% missing: BILLING-PROV-NPI-NUM (COT00002)
MIS-6-007-7	% missing: BILLING-PROV-NPI-NUM (COT00002)
MCR-9-006_2-19	% of PCCM capitated payments with a non-missing plan ID where plan ID number equals the Billing Provider Number or Billing Provider NPI Number
MCR-61-007-7	% of claim headers with Billing Provider NPI Number in an invalid format
MCR-60-007-7	% of claim headers with Billing Provider NPI Number in an invalid format
MCR-13-006_2-19	% of PCCM capitated payments with a non-missing plan ID where plan ID number equals the Billing Provider Number or Billing Provider NPI Number
FFS-51-007-7	% of claim headers with Billing Provider NPI Number in an invalid format

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP180	CIP.002.180	BILLING-PROV-NPI-NUM	CIP00002	CLAIM-HEADER-RECORD-IP
CLT131	CLT.002.131	BILLING-PROV-NPI-NUM	CLT00002	CLAIM-HEADER-RECORD-LT
CRX071	CRX.002.071	BILLING-PROV-NPI-NUM	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/12/2024	3.29.0	COT.002.113	UPDATE	Definition	The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one.	The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one.
09/12/2024	3.29.0	COT.002.113	UPDATE	Coding requirement	1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.002.081)	1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When Type of Claim (COT.002.037) not in [3,C,W] then value must match Provider Identifier (PRV.002.081)6. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization)
08/09/2023	3.11.0	COT.002.113	UPDATE	Definition	The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.	The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one.
06/24/2022	3.0.0	BILLING-PROV-NPI-NUM	UPDATE	Data Dictionary	\|DE No\|Data Element Name\|Definition\| \|CIP180\|BILLING-PROV-NPI-NUM\|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).\|	\|DE No\|Data Element Name\|Definition\| \|CIP180\|BILLING-PROV-NPI-NUM\|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.\|
06/24/2022	3.0.0	BILLING-PROV-NPI-NUM	UPDATE	Data Dictionary	\|DE No\|Data Element Name\|Definition\| \|CLT131\|BILLING-PROV-NPI-NUM\|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).\|	\|DE No\|Data Element Name\|Definition\| \|CLT131\|BILLING-PROV-NPI-NUM\|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.\|
06/24/2022	3.0.0	BILLING-PROV-NPI-NUM	UPDATE	Data Dictionary	\|DE No\|Data Element Name\|Definition\| \|COT113\|BILLING-PROV-NPI-NUM\|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).\|	\|DE No\|Data Element Name\|Definition\| \|COT113\|BILLING-PROV-NPI-NUM\|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.\|
06/24/2022	3.0.0	BILLING-PROV-NPI-NUM	UPDATE	Data Dictionary	\|DE No\|Data Element Name\|Definition\| \|CRX071\|BILLING-PROV-NPI-NUM\|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).\|	\|DE No\|Data Element Name\|Definition\| \|CRX071\|BILLING-PROV-NPI-NUM\|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.\|
07/15/2022	3.0.1	COT113	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT113\|BILLING-PROV-NPI-NUM\|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT113\|BILLING-PROV-NPI-NUM\|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one.