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RULE-1541
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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.
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RULE-1542
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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).
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RULE-1543
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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.
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RULE-1544
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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).
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RULE-7303
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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.
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RULE-7489
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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.
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RULE-7509
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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.
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RULE-7766
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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.
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RULE-7826
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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.
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RULE-7907
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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.
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RULE-7911
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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.
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