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Assuring that all information submitted on a claim is in the correct location and format not only complies with rules established by the Centers for Medicare and Medicaid Services (CMS), but also promotes prompt claim turnaround time and payment.  The following guidelines were instituted by CMS as part of the 5010 implementation:

Professional Claims

Billing Provider Address - Loop 2010AA Segment N3/N4 

• Must be a physical street address
• Must contain a valid 9 digit zip code
• Billing Provider Address is populated in box 33 on CMS-1500 paper claim forms

Pay to Address - Loop 2010AB, Segment N3

• Can be a physical street address or a PO Box address
• This field does not exist on CMS-1500 paper claim forms

Pay to Plan - Loop 2010AC, Segment N3/N4

• Can be a physical street address or a PO Box address
• This field does not exist on CMS-1500 paper claim forms

Service Facility Location - Loop 2310C, Segment N3/N4 (This field is not required if same as Billing Provider Address)

• Can be a physical street address of PO Box address
• Must contain a valid 9 digit zip code
• Service Facility Location is populated in box 32 on CMS-1500 paper claims

NPI Rules for Professional Claims

• 33A cannot be left blank.  Populate with the individual provider's NPI if a sole practitioner.  Populate with the group practice NPI if not a sole practitioner.
• If the provider of service is a sole practitioner, boxes 24J and 31 should be left blank.  The sole practitioner's name and NPI should be populated in boxes 33 and 33A.  Please note:  Do not populate a group practice name in box 33 for sole practitioner.
• If the provider of service is not a sole practitioner, the provider of service's name and NPI should be populated in boxes 31 and 24j.  The group practice NPI is populated in box 33A.

Institutional Claims

Billing Provider Address - Loop 2010AA, Segment N3/N4

• Must be a physical street address
• Must contain a valid 9 digit zip code
• Billing Provider Address is populated in box 1 on UB-04 paper claim forms

Pay to Address - Loop 2010AB, Segment N3

• Can be a physical street address or a PO Box address
• Pay to Address is populated in box 2 on UB-04 paper claim forms

Pay to Plan - Loop 2010AC, Segment N3

• Can be a physical street address or a PO Box address
• Must contain a valid 9 digit zip code

Service Facility Location - Loop 2310E, Segment N3/N4

• Must be a physical street address
• Must provider a valid 9 digit zip code

NPI Rules for Institutional Claims

• The facility NPI is required in box 56 on UB-04 claims.
• When populating physician names in boxes 76-79, the physicians' individual NPI numbers must also be included. 

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