We’ve enhanced Benefit Explainer to include new payability limitation

Benefit Explainer users may have started seeing a new payability limitation regarding the National Provider Identifier, beginning Aug. 1, 2022. We first alerted users to the change in an Aug. 1 provider alert.

The National Provider Identifier, available under the Medical/Payment Policy and Benefit Package Report tabs in Benefit Explainer, is a government ID issued to medical professionals and businesses. Assigned and managed through the National Plan and Provider Enumeration System, this 10-digit numeric number is used to verify valid values.

The new limitation can appear as a stand-alone rule or as a combination rule with another limitation. It can appear in any of the following fields:

• Coverage Limitations
• Medical
• Benefit Limitations
• Provider Payment Limitations
• Authorization Assignment
• Member Cost Share
• Maximums
• Cost Sharing
• Accumulator and Counted Events

See screenshots below for examples of how the NPI may appear as a standalone rule or as a combination rule with a primary diagnosis.

When a user clicks on the link in the National Provider Identifier, Benefit Explainer will open a new tab. In the new tab, the user can view the specific National Provider Identifier code, as follows:

Note: Screenshots are provided for illustrative purposes only and may not represent actual data.