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During October 2012, Midlands Choice will implement updates to Provider Matching Logic (PML).  PML is the automated series of rules and decisions used when repricing claims that were submitted on paper or electronically that determine if the provider of service is participating and what reimbursement terms to use based on the information provided on the claim.  The following PML changes will be implemented to improve the accuracy of repricing in accordance with recent compliance changes:

• Using the 5010 requirement of submitting 9 digit zip codes for service and billing addresses, Midlands Choice will be able to determine provider participation and reimbursement at the practice address level.  
• The requirement of submitting National Provider Identifier (NPI) numbers on claims will allow Midlands Choice the ability to confirm an accurate match has been made by comparing the NPI submitted on the claim to the NPI provided at the time of credentialing.

In order to assist in this implementation, please make sure that all address changes are sent to Midlands Choice as soon as they are known.  Delegated payers require a 30 day advanced notice to implement the changes.

Although these updates will be mostly transparent, clean billing and timely notification of demographic changes are more important than ever to ensure accurate processing of claims.  All provider demographic updates, including address, name, and tax identification number changes should be communicated to Midlands Choice using the Demographic Update Form at least 60 days before they are used on claims.  

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