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The Affiliation Edit: What It Is and How to Prevent It

Tuesday, December 4, 2018

Some providers may have seen EOB 07025 - THE RENDERING PROVIDER IS NOT AFFILIATED WITH YOUR PROVIDER GROUP. CONTACT THE RENDERING PROVIDER AND ASK THEM TO COMPLETE A MANAGED CHANGE REQUEST ADDING YOUR PROVIDER GROUP NPI ON THE AFFILIATED PROVIDER PAGE WITHIN THE NEXT FOUR WEEKS TO PREVENT CLAIMS BEING DENIED on their claim remittance advice (RA). This edit is in place to ensure billing providers are affiliated with the rendering (individual) providers for whom they are billing to prevent inaccurate payment or fraud. The edit will apply if a rendering/ individual provider is required for the claim and the rendering/individual provider’s NPI is not affiliated with the billing provider.

The intent was to alert providers to situations in which affiliation relationships do not exist. This allows rendering providers to initiate an abbreviated Manage Change Request (MCR) to add the affiliation to the provider record. The rendering provider should complete an abbreviated MCR to add the provider group NPI to the Affiliated Provider page to avoid claim denials. Abbreviated MCRs are processed on submission.

Author: 
NC Medicaid Provider Services, 919-855-4050