Referring provider, Ordering provider and billing provider FAQ

Q: What is the difference between an “ordering/referring provider” and a “billing provider”?

A: An ordering/referring provider is the individual who orders or refers an item or service for a Medicare beneficiary (e.g., laboratory diagnostic tests, imaging services, specialty services, durable medical equipment) that will be furnished and billed by another provider or supplier (e.g., laboratory, imaging center, specialist, DME supplier).

The billing provider is the individual or organization that furnishes and bills Medicare for the ordered/referred service provided to the beneficiary.


Q: Where do I indicate referring or ordering provider’s information on my claim?

A: Indicate the referring or ordering provider’s information in the section titled Name of referring provider or other source (Item 17 & 17b of the CMS-1500 paper claim form or the 2310A Referring Provider Loop, segments NM101 using qualifier DN or DK, NM103-NM105 [Name], NM108 using [XX] qualifier, and NM109 [NPI] of the 837P electronic claim) as indicated below.

• Report the name of the referring or ordering practitioner of a service in Item 17 (837P 2310A loop, segment NM1) and the appropriate qualifier to the left of the dotted line on the CMS-1500 (02/12) claim form: DN (referring provider) or DK (ordering provider)

• No information should appear in Item 17a (837P 2310A loop, segment REF02). Item 17a was formerly used to report the Unique Physician Identification Number (UPIN), which is no longer used -- leave this item blank. Information appearing in this item or loop will cause your claims to be returned as unprocessable and rejected electronically.

• Report the National Provider Identifier (NPI) of the referring/ordering provider in Item 17b or the 837P 2310A Referring Provider Loop, segments NM101 using qualifier DN (referring provider) or DK (ordering provider), NM103-NM105 [Name], NM108 using [XX] qualifier and NM109 [NPI].
• Note: When a service is referred or ordered by another practitioner, a valid NPI is required and must be reported. Your claims will be returned as unprocessable if the NPI is required and is missing, invalid or submitted in the wrong item (e.g., a valid NPI submitted in Item 17a).


Q: When responding to a CERT request for medical records, can records from a referring or consulting physician be included?
A. Yes. It is the responsibility of the provider who was reimbursed by Medicare for the service to procure any documentation necessary from another party.

Q: Where do I indicate my billing entity’s provider number on my claim?

A: The billing entity’s National Provider Identifier (NPI) should be reported in the 2010AA Billing Provider Loop of the 837P electronic claim or Item 33a of the CMS-1500 paper claim form.

Important note: The NPI of the billing provider is required on all claims. Paper claims will be returned as unprocessable and electronic claims may be rejected if:

• Any information appears to be missing or invalid in the 837P 2010AA loop, REF02. Item 33b of the paper form should be left blank.
• The billing provider’s NPI is missing, invalid, or is located in the wrong area (e.g., valid NPI submitted in Item 33b.)

Reminder: When billing services rendered by an individual associated with an incorporated entity or a group, the individual practitioner’s NPI must be reported in the Rendering Physician’s area (the 2310B Rendering Provider Loop of the 837P electronic claim or Item 24J of the paper claim form) and the billing entity or group identifier would be reported as indicated above. If billing services for an independent lab, ambulatory surgical center (ASC), independent diagnostic testing facility (IDTF), ambulance supplier, or solo practitioner not associated with a group, a rendering provider identifier in Item 24J or loop 2310B is not required.

Q: What are the requirements for a provider to be eligible to order or refer items or services for a Medicare beneficiary?

A: According to the Centers for Medicare & Medicaid Services’ (CMS’) change request (CR) 6417 external pdf file, a provider is eligible to order or refer items or services for a Medicare beneficiary only if he or she meets both of the following criteria:

• The ordering/referring provider must be enrolled in Medicare and have a current enrollment record in the Provider Enrollment, Chain and Ownerships System (PECOS).
• The ordering/referring provider must be classified as a provider who is eligible to order or refer:
• Doctor of medicine or osteopathy
• Dental medicine
• Dental surgery
• Podiatric medicine
• Optometry
• Physician’s assistant
• Certified clinical nurse specialist
• Nurse practitioner
• Clinical psychologist
• Certified nurse midwife
• Clinical social workers
Note: Only Medicare-enrolled physicians and non-physician practitioners that meet the above criteria are eligible to order/refer services for Medicare beneficiaries.

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