User Guide — Taxonomy Codes

1. Determine which taxonomy code corresponds to your medical group's "type" and "specialty" on file with the payer. Contact the payer directly if you need help determining your taxonomy code.
2. Display the Payer Enrollment page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Enrollment and Numbers, click Payer Enrollment.
3. Under the Group-Level Information heading, locate the medical group in the list and click edit to display the billing group details.
4. In the upper right corner, click Advanced View (if this link appears).
5. Organizational taxonomy code — Select the taxonomy code for this medical group.
6. Click Save.

1. Determine which taxonomy code corresponds to your provider. Contact the payer directly if you need help determining your taxonomy code.
2. Display the Payer Enrollment page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Enrollment and Numbers, click Payer Enrollment.
3. Under the Provider-Level Information heading, locate the provider in the list and click edit to display the provider details.
4. In the upper right corner, click Advanced View (if this link appears).
5. Provider taxonomy code — Deselect the use provider default? option and select the taxonomy code for this provider.
6. Click Save.

1. Determine which taxonomy code corresponds to the referring provider's specialty. Contact the referring provider directly if you need help determining their taxonomy code.
2. Enter the taxonomy code into athenaOne from the Referring Providers page.
3. Click the choose link to select the specific referring provider from the lookup.
4. Click the update link for the appropriate referring provider name.
5. Select a taxonomy type from the Taxonomy Code menu and then click select next to the appropriate taxonomy description.
   Note: You must select taxonomy codes by description, not by the code itself. If you know the 10-character taxonomy code that you want to use, you can look up the description.

 

The three levels of a taxonomy code are as follows:

• First level: Provider type — Describes the major healthcare grouping of the provider, for example, Medical Doctor or Dentist.
• Second level: Provider classification — Supplies more detail about the provider's specialty, for example, Internal Medicine or Orthopedics.
• Third level: Provider specialty — Supplies the most specific data about a provider's focus, for example, Orthopedic Surgery or Pediatric Cardiology.

 

The two taxonomy code types are as follows:

• Individual taxonomy code describes the specialty of an individual provider.
• Medical group taxonomy code describes the specialty of the medical department.

 

With the advent of NPI, the taxonomy code is extremely important because payers now use them to cross-walk between the provider/medical group NPI number and their provider/medical group legacy number in the payer adjudication system.

 

This means that your practice must enter taxonomy codes in athenaOne for referring providers and/or medical groups in addition to the taxonomy codes for their providers.

 

Selecting the correct taxonomy code for each provider is critical because it ensures identification of a provider in the payer adjudication systems and enables prompt reimbursement.

 

Taxonomy codes are entered in several places in athenaOne. The table below illustrates where taxonomy codes can be entered and for which purpose you would use each code.

 

Where to Enter Taxonomy Codes in athenaOne
athenaOne Page	Field Name	Type of Taxonomy Code	Purpose
Providers	Provider Taxonomy	Individual	The provider's default taxonomy code.
Payer Enrollment	Provider Taxonomy Code Override	Individual	A payer-specific taxonomy code, to be used only when billing that payer.
Payer Enrollment	Medical Group Taxonomy Code Override	Individual or Group	A payer-specific taxonomy code, to be used only when billing that payer. This code overrides the taxonomy code entered for the medical group in the Medical Group Number table.
Payer Enrollment	Organizational Taxonomy Code	Group	A payer-specific taxonomy code, to be used only when billing that payer.
Referring Providers	Provider Taxonomy	Individual	The taxonomy code for the referring provider.

 

If a medical group taxonomy code is required, enter it using the Payer Enrollment page for each provider number category where the taxonomy code is needed for billing.

 

 

The taxonomy codes are mapped to certain claim formats by default. The table below illustrates the claim formats, taxonomy codes, and fields that are mapped by default.

 

Taxonomy Code Default Mapping
Claim Format	Taxonomy Code Type	Field	Notes
ARBREASTCARE	Group	1b
ARBREASTCARE	Individual	1b	Sent instead of Group Taxonomy Code if the claim is billed with an individual provider
FORM5	Group	1
FORM5	Individual	1	Sent instead of Group Taxonomy Code if the Individual Billing Flag is set
ILFORM1443	Individual	19	This form is set up to map the default Provider Taxonomy Code, and does not map overrides unless set by a rule.
ILFORM3797	Individual	28	This form is set up to map the default Provider Taxonomy Code, and does not map overrides unless set by a rule.
MASSHEALTH	Group	1
MASSHEALTH	Individual	1	Sent instead of Group Taxonomy Code if the Individual Billing Flag is set
UB04	Group	FL81	Sent with B3 qualifier
ANSI837	Group	2000A PRV03	Sent if CSC NPI Status is not 1
ANSI837	Individual	2000A PRV03	Sent instead of Group Taxonomy Code if CSC NPI Status is not 1 and Individual Billing Flag is set
ANSI837	Individual (Referring Provider)	2310A PRV03	Sent if populated in the claim hash

 

When the taxonomy code should be mapped to a format conditionally rather than constitutively, it's often best to use a rule. In addition, practices can set up their own local rules to map taxonomy codes.

 

There are four major rules involved in taxonomy codes:

 

5613: This rule fires on all claims where a taxonomy ID is present and changes it to an ANSI standard taxonomy code. The taxonomies are stored in athenaOne as athenaOne-specific ID numbers, so they must be changed to the ANSI codes before being mapped to the claim.

 

6285: This rule fires on certain Claim Submission Categories and Insurance Reporting Categories. If the payer has been identified as requiring taxonomy codes, rule 6285 will hold the claim if the taxonomy is not present. The rule can look for the medical group taxonomy, the provider taxonomy, the referring provider taxonomy, or any combination of the three for each payer.

 

6286: This rule fires on certain Insurance Reporting Categories and maps the taxonomy codes to the CMS-1500.

 

6241: This rule fires on certain Claim Submission Categories and Insurance Packages and maps the taxonomy codes to the CMS-1500.