Have you ever entered a provider number into Genie only to receive a warning to advise the number is incorrect? How does Genie know this is the case?
A doctor's provider number is issued by Medicare and helps identify the doctor and the location that they are providing services at. These provider numbers are comprised of:
- Provider Stem = a 6-digit number
- 1 Practice Location Character (PLV)
- 1 Check Digit
Validating the provider number
In order to ensure provider numbers are legitimate, Medicare have an algorithm they apply to provider numbers in order to 'validate' a number. The algorithm used for the Provider Check Digit is:
(digit 1 x 3) + (digit 2 x 5) + (digit 3 x 8) + (digit 4 x 4) + (digit 5 x 2) + (digit 6) + (PLV x 6)
You then need to divide the result by 11. The remainder is allocated an alpha that is the Provider Check Digit (see table below for details).
Example
To make it easier to understand how the equation works below is an example using the provider number 988939BK.
| Digit 1 | Digit 2 | Digit 3 | Digit 4 | Digit 5 | Digit 6 | PLV | Check Digit |
| 9 | 8 | 8 | 9 | 3 | 9 | B | K |
= (9 * 3) + (8 * 5) + (8 * 8) + (9 * 4) + (3 * 2) + (9) + (11 * 6)
= 27 + 40 + 64 + 36 + 6 + 9 + 66
= 248
Now divide 248 by 11 = 22 r 6 (11 goes into 248 22 times with 6 left over). If we then look up 6 in the Provider Check Digit table you will see it equates to a J. As such the provider number listed above is incorrect and instead should be 988939BJ.
Practice Location Character
The Practice Location Character indicates the order of the practices that a provider has been registered at. Each Practice Location Character is allocated a Practice Location Value (PLV) that is used in the Provider Check Digit Routine.
Check Digit
The check digits for the resultant remainder are as follows:
| Practice Location Character | Check Digit | ||||
| Character | Value | Character | Value | Remainder | Check Digit |
| 0 | 0 | G | 16 | 0 | Y |
| 1 | 1 | H | 17 | 1 | X |
| 2 | 2 | J | 18 | 2 | W |
| 3 | 3 | K | 19 | 3 | T |
| 4 | 4 | L | 20 | 4 | L |
| 5 | 5 | M | 21 | 5 | K |
| 6 | 6 | N | 22 | 6 | J |
| 7 | 7 | P | 23 | 7 | H |
| 8 | 8 | Q | 24 | 8 | F |
| 9 | 9 | R | 25 | 9 | B |
| A | 10 | T | 26 | 10 | A |
| B | 11 | U | 27 | ||
| C | 12 | V | 28 | ||
| D | 13 | W | 29 | ||
| E | 14 | X | 30 | ||
| F | 15 | Y | 31 | ||
The end result...
So, now that you feel like you've just been back in a high school mathematics class what is the take home message? When Genie tells you a provider number you're entering is incorrect it's not because we want to make your life more difficult, we promise! It's because the number you've entered fails Medicare's algorithm and as such is indeed incorrect (despite what the referral letter in your hand may say)! If you were to submit a claim with those credentials to Medicare they would reject it, so Genie is trying to save you (and your patients) having to reclaim for these services.