The Service Providers section provides additional information relating to the claim on the line level. The Service Providers fields are defined by section below:
Rendering Provider Information: This section provides information about the rendering provider on a service line level.
Rendering provider last name or organization name. The rendering provider is the person or company (laboratory or other facility) who provided the care.
Rendering provider first name.
Rendering provider middle name or initial.
Suffix to individual name.
Rendering provider identification.
Provider Taxonomy CodeProvider Taxonomy Code
Code designating the provider type, classification, and specialization of the rendering provider for this claim. The taxonomy can be different for the same provider on different claims.
Secondary IDsSecondary IDs (button)
Rendering provider secondary identifier. Options are:
| 0B | State License Number |
| 1G | Provider UPIN Number. UPINs must be formatted as either X99999 or XXX999. |
| G2 | Provider Commercial Number. This code designates a proprietary provider number for the destination payer identified in the Payer Name loops, Loop ID-2010BB, associated with this claim. This is to be used by all payers including Medicare, Medicaid, Blue Cross, etc. |
| LU | Location Number |
Assistant Surgeon Information: This section provides information about the assistant surgeon on a service line level. This information is required when a claim involves a referral.
Assistant surgeon last name or organization.
Assistant surgeon first name.
Individual middle name of assistant surgeon.
Suffix to individual name.
Assistant surgeon primary identifier.
Secondary IDsSecondary IDs (button)
Assistant surgeon secondary identifier. Options are:
| 0B | State License Number |
| 1G | Provider UPIN Number |
| G2 | Provider Commercial Number |
Supervising Provider Information: This section provides information about the supervising provider on a service line level. This information is required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line.
Individual last name or organizational name of supervising provider.
Individual first name of supervising provider.
Individual middle name of supervising provider.
Suffix to individual name.
Other payer primary identifier.
Secondary IDsSecondary IDs (button)
Supervising provider secondary identifier. Options are:
| 0B | State License Number |
| 1G | Provider UPIN Number |
| G2 | Provider Commercial Number |
| LU | Location Number |
Service Facility Location Information: This section provides information about the service facility location on a service line level. The purpose is to identify specifically where the service was rendered.
Laboratory or Facility NameLaboratory or Facility Name
Individual last name or organizational name where the patient received treatment.
Address Lines 1 & 2Address Lines 1 & 2
Address information of the service facility.
Laboratory or facility postal zone or zip code. When a user enters a zip code in a zip code field and clicks tab to move to the next field, the city and state fields are automatically generated based on data received from the USPS. Note: This replaces any data already entered in the city/state fields.
Laboratory or facility city name.
Laboratory or facility state or province code.
Code identifying the country of the laboratory or facility.
Subdivision CodeSubdivision Code
Code identifying the country subdivision.
Service Facility NPIService Facility NPI
Laboratory or facility primary identifier.
Secondary IDsSecondary IDs (button)
Service facility location secondary identifier. Options are:
| OB | State License Number |
| G2 | Provider Commercial Number |
| LU | Location Number |
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