Introduction

This guideline document explains how the zHealth system automatically populates provider and/or practice taxonomy information in the EDI 837 Professional (837P) files, and how the same taxonomy information is also populated on the CMS-1500 claim form. The taxonomy code is required (if the payer needs it) to classify the type, classification, and specialisation of the provider and/or practice.

Note: A taxonomy number is basically the 10-digit taxonomy code assigned to a healthcare provider/facility that identifies their speciality, classification, or type of service they provide.

X12 Standard

In the X12 837 Professional (837P) EDI transaction, taxonomy information for both the rendering provider and billing provider is included in the PRV segment, as I explained below

Billing Provider Taxonomy

Purpose: Indicates the taxonomy code for the billing provider (e.g., a clinic or group)

• Loop 2000A: Billing Provider Hierarchical Level

• Segment PRV: Billing Provider Speciality Information

• Segment Format: PRV*BI*PXC*<taxonomy code>
  
  

Example: PRV*BI*PXC*XXXXXXXXXX

• BI = Billing Provider

• PXC = Provider Taxonomy Code

• XXXXXXXXXX= Taxonomy Number

Condition:

If Box 33b is configured as "zz":

  If the provider billing type is organisation:

Organisation taxonomy will come

  else:

Provider taxonomy will come

else:

nothing will come

Rendering Provider Taxonomy

Purpose: Specifies the taxonomy code for the rendering provider (individual who performed the service)

• Loop 2310B: Rendering Provider Name (if different from Billing Provider)

• Segment PRV: Rendering Provider Speciality Information

• Segment Format: PRV*PE*PXC*<taxonomy code>

Example: PRV*PE*PXC*XXXXXXXXXX

• PE = Rendering Provider

• PXC = Provider Taxonomy Code

• XXXXXXXXXX= Taxonomy Number

Condition:

If the provider billing type is Organisation:

Provider taxonomy will come in the "PRV" segment

  If box 24ij is configured to "zz":

nothing will come "REF" segment will not come

  else if box 24ij is configured:

The configured value will come in the "REF" segment

  else:

State licence of the provider will come in the "REF" segment

else:

nothing will come

CMS-1500 Paper Claim Standard

Taxonomy Number is not always required on the CMS-1500 claim form; some payers (Example: Medicaid) require a taxonomy number in Box 33b and Box 24ij, using the "ZZ" qualifier to indicate the type of code.

Billing Provider Taxonomy Number: Box 33b

Purpose: Identifies the billing provider taxonomy.

Format: ZZ qualifier followed by the 10-digit taxonomy number.

By default, the system does not populate the taxonomy number in Box 33b of the CMS-1500 claim form. The clinic must configure this individually for each “payer” that requires taxonomy details. To configure this, follow the steps below:

• Go to Update Info > Insurance Master tab

• Find and select the payer for which you want to send the taxonomy details

• Locate the field labelled Billing Provider Other ID- HCFA 1500 Box 33b

• From the dropdown, select the qualifier ZZ (taxonomy qualifier)

Rendering Provider Taxonomy Number: Box 24i and 24j

Box 24i

• Enter qualifier ZZ in the shaded portion.

• Only used if the taxonomy code is being reported in 24j (shaded).

Box 24j

• Enter the 10-digit taxonomy number of the rendering provider.

• Goes in the Box 24j, above the NPI (which goes in the shaded box)

By default, the system does not populate the taxonomy number in Box 24ij of the CMS-1500 claim form. The clinic must configure this individually for each payer that requires taxonomy details. To configure this, follow the steps below:

• Go to Update Info > Insurance Master tab

• Find and select the payer for which you want to send the taxonomy details

• Locate the field labelled Other ID- HCFA 1500 Box 24i (shaded)

• From the dropdown, select the qualifier ZZ (taxonomy qualifier)

NOTE: The taxonomy details displayed on the CMS-1500 claim form do not necessarily mean it will be populated in the corresponding loop/segment of the EDI 837P file.

Taxonomy Populate on the EDI 837P in zHealth Based on Payer Configuration

33b (Billing Provider Taxonomy) is set in the Payer

Loop 2000A for Billing Provider Taxonomy is populated

• When the provider type is Individual, the Provider Taxonomy from the Provider tab is used

• When the provider type is Organisation, the Facility Taxonomy from the Facility tab is used

24i/j (Rendering Provider Taxonomy) are set in the Payer

Loop 2310B for Rendering Provider Taxonomy is populated:

• If the provider type is Individual, no taxonomy will be populated in Box 24i/j

• If the provider type is Organisation, the Provider Taxonomy from the Provider tab will populate Box 24i/j

FAQs

Q. If the Billing Provider is set to an organisation. Do we populate Taxonomy on the EDI file?

In this case, Provider taxonomy will be populated in Loop 2310B Segment PRV, and also the State License Number will be populated in the EDI 837p file [Loop 2000C] in the REF segment.

Example: 

• PRV*PE*PXC*Provider Taxonomy~

• REF*0B*Provider State License Number ~

Q. If the Billing Provider is set to an individual. Do we populate Taxonomy on the EDI file?

In this case, Provider taxonomy will not populate in Loop 2310B Segment PRV, and also the State License Number will not populate in the EDI 837p file [Loop 2000C] in the REF segment. 

However, the State License Number for the Practice will be populated in the Loop 2310C Segment REF

Example: REF*0B*Practice State License Number~

Q: What happens when the 24i/j from the Insurance Master is configured and the Billing Provider is set to Organisation in the Provider tab?

In this case, the system will populate only Provider Taxonomy in the Loop [2310B] segment PRV. 

Also, to note, the State License number in the REF segment will not be populated.

Example: PRV*BI*PXC*Provider Taxonomy~

Q: What happens when the Box 33b from the Insurance Master is configured ZZ? What did we populate on the EDI file?

In this case, the taxonomy detail will be populated in Loop 2000A Segment PRV. The system will pull the taxonomy number depending on what the Billing Provider Type i.e, if the type is individual, then Provider taxonomy is pulled, and if the type is set to organisation, then organisation taxonomy is pulled on the EDI.

Example:

• PRV*BI*PXC*PracticeTaxonomy~

• PRV*PE*PXC*Provider Taxonomy~