Clarification re: Affiliation Edit and Claim Denials

One of the requirements associated with the implementation of NCTracks is that attending/rendering providers must be affiliated with the billing providers who are submitting claims on their behalf. The Edit associated with this requirement is # 07025. Providers who have denied claims with Edit #07025 on their Remittance Advice may have thought it was the cause of the denial, but it is not. The disposition of Edit # 07025 has been set to "pay and report" since NCTracks went live on July 1.

The "pay and report" disposition means that claims where the attending/rendering provider is not affiliated with the billing provider will not deny, but the Edit and EOB will post on the provider's Remittance Advice. The intent is to alert providers to situations in which the affiliation relationship does not exist, so the attending/rendering provider can initiate a Manage Change Request. The text of the EOB reads, "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."

Note that the Manage Change Request to establish or change a provider affiliation must be initiated by the Office Administrator of the attending/rendering provider. The group or hospital that is the billing provider cannot alter affiliations in NCTracks.

Providers are encouraged to correct any affiliation issues right away. The State will provide 45 days notice to providers before the disposition of this edit is changed to "deny." Once the disposition is changed, a claim failing the edit will suspend for four weeks. If the affiliation relationship is not established within that time period, the claim will be denied.