Understanding Referring, Ordering, and Rendering Providers

Understanding Referring, Ordering, and Rendering Providers

Being behind on a healthcare billing assignment is not a simple one in today’s complex society. There is a lot going on. There is a whole set of players in this complicated financial cycle that covers all of the billing and claims steps. I will give an over view definition of each of these players which includes referring providers, ordering providers and rendering provider. Then we will take a look on some of the standard claim forms used in each of the steps of claims production to get the story behind the billing process. Some of these claim forms are known as UB-04 and CMS-1500. I will explain to you the definitions and the purposes of each one of these forms. The key suggestions before you continue on reading this guide is that you must know what is a referring provider, ordering provider and rendering provider to make a valid medical claim otherwise your claim will be discounted by CMS and will go in the list of dead beat claimants who failed to follow instructions in the medical billing process.

1. Referring Provider

1.1 What is a Referring Provider?

A referring provider is an individual, often a primary care physician (PCP), who refers or suggests that a patient receive care from another provider or facility. Referring providers play an important role in the referral process and assure that the specialist consult is indicated and appropriate for the patient’s condition.

1.2 Referring Provider Meaning

‘Referring provider’ is the term used for the clinician (eg, the primary care clinician) making the referral when it’s understood that another provider’s care will be needed (eg, a general internist may seek services from other clinicians such as a specialist, laboratory, imaging centre, hospital and so forth).

1.3 Referring Provider vs. Rendering Provider

Though a referring provider identifies the need for specialised care and initiates the referral, a rendering provider relates to the trusted healthcare professional or facility that actually provides the patient with services recommended by the referring provider. The referring provider leans on the service offering and expertise of the rendering provider to care for the patient.

1.4 Difference Between Referring and Rendering Providers

The distinction between referring and rendering service providers has to do with their respective roles in caring for the patient’s needs within a clinical team. More specifically, the referring provider refers the patient to a rendering service provider, who in turn renders the necessary service. The division of labour that exists between a referring provider and a rendering provider results in a patient receiving the service needed to address their clinical needs.

2. Ordering Provider

2.1 What is an Ordering Provider?

An ordering provider authorises or prescribes services, treatments or procedures to be provided to a particular patient by an organisation. For example, an ordering provider could request a specific diagnostic test or therapeutic procedure, or refer the patient to another HCP for care. An ordering provider still participates in the care continuum, but they are responsible for the general diagnosis or recommended course of care.

2.2 Ordering Provider Meaning

We can call that ordering provider.In his AMA monograph, Pendergrass provides the following definition for the ordering provider: It is always the ordering provider who initiates the request for services, whether these services are a laboratory test, an imaging study, or a consultation with a specialist. He/she determines which services are best suited to help in diagnosis, treatment or management of the patient’s condition.

2.3 Ordering Provider vs. Referring Provider

While referring refers to the identification of needs for other types of care beyond the practice of the referring provider, ordering refers to the prescription or authorisation for delivery of specific medical services or procedures. Whereas referring physicians typically direct their patients to particular other healthcare providers, the ordering provider often focuses on the tests or treatments specifically needed for patient care.

2.4 Ordering Provider vs. Rendering Provider

An ordering provider is the one who prescribes or authorises the services; a rendering provider is the one who actually delivers them to the patient. For instance, while the ordering provider is supposed to make sure that the right test, treatment or procedure is ordered, it is up to the rendering provider to carry out those orders.

3. Rendering Provider

3.1 What is a Rendering Provider?

A rendering provider is a health-care provider or facility providing the prescribed or authorised medical service to the patient, or providing the necessary care or treatment authorised by the ordering or referring provider.

3.2 Rendering Provider vs. Referring Provider

A referring provider is that provider who recognises the need for specialised care for a patient and initi service that the referring provider recommended for the patient. Referring providers depend on the services rendered by rendering providers to meet the specialised needs of the patients.

3.3 Rendering Provider vs. Billing Provider

The entity providing the medical services is the rendering provider; the one responsible for submitting the claims and invoices for payment is the billing provider. The rendering provider must give us the care; the billing provider files all the claims (or invoices for service not covered by insurance) for our providers to be paid.

4. UB-04 Form

4.1 What is the UB-04 Form?

The UB-04 form (CMS-1450) is a standardised billing form for hospitals, clinics, health maintenance organisations (HMOs), and other healthcare facilities to submit claims to insurance carriers for services provided. Information captured includes patient information, date/times of these services, and what those services cost.

4.2 UB-04 vs. CMS-1500 Form

If the first one – the UB-04 – targets facilities, the second one, the so-called CMS-1500, is the claim form used by individual physicians and other healthcare providers to submit claims for their services to insurance company clearinghouses. The UB-04 provides space for institutional providers’ own billing idiosyncrasies, whereas the cover sheet allots insufficient space for individual providers.

4.3 Purpose of the UB-04 Form

This UB-04 form’s main function is to help billing for institutional medical providers to complete and submit claims to payers in a way that they can see and verify all the information, such as the patient’s demographic, diagnosis, treatment procedure, or any other information that may be involved in the patient’s bill.

4.4 UB-04 Form Definition

The UB-04 ‘standard monthly instructional bill for institutional health services, Part A’ was produced by the National Uniform Billing Committee (NUBC) for the submission of institutional claims that uniformly detailed charges sent to payers such as third-party insurers.

4.5 UB-04 Form Used For

The UB‑04 is a ‘uniform bill’ that hospitals, clinics, nursing homes and other institutional-based health care providers use to submit claims to insurance payers for services rendered. For outpatients, the equivalent form is the CMS-1500, and these blank forms can be found online. The UB-04 lists every aspect of the patient’s stay – room and board charges, procedures performed, supplies and medications administered to the patient during admission.

5. CMS-1500 Form

5.1 What is the CMS-1500 Form?

The CMS-1500 form (also known as the HCFA-1500 form) is a standard claim form for individual providers to bill their patients for the care they have provided. The form includes information about the provider, their patient and the services rendered.

5.2 CMS-1500 vs. UB-04 Form

The form used to bill for institutional providers such as hospitals and nursing homes and other large health care providers is called the UB-04. However, the CMS-1500, which I’ll discuss in more detail, is the form designed specifically for the individual healthcare provider – the physician, the psychotherapist and any other non-institutional personnel. The information on the CMS-1500 is different from other bills because it focuses on the services of a professional.

5.3 Purpose of the CMS-1500 Form

A view of the reality behind cherry-picking: the CMS-1500 form for individual providers to bill for their claims. The form specifies the services provided with corresponding diagnostic and procedure codes and other supplementary information that processing of claims depends on.

5.4 CMS-1500 Form Definition

The CMS-1500 is a pre-printed standard claim form provided by the Centers for Medicare and Medicaid Services that is used by all individual providers to submit their claims. It enables payers, including insurance companies, to process the claims for reimbursement in a standardised format.

5.5 CMS-1500 Form Used For

The standard form used by individual healthcare providers – clinicians, therapists and other individual practitioners who are not based in institutions – to submit claims and bills for professional services provided to patients. It contains information that is essential for a submitted claim, including provider information, patient demographics, diagnosis codes, procedure codes, and other account information.

FAQs (Frequently Asked Questions)

6.1 What does "referring provider" mean?

A referring provider is a health professional who recommends or requests that a patient seek specialised care or receive specific medical services from another healthcare provider or facility who is better equipped to provide that particular care for the patient. Referring providers often help to facilitate and maintain continuity of care for their patients by recognising where their expertise might end and another provider should be consulted.

6.2 What is the purpose of the UB-04 form?

The UB-04 form is designed for the purpose of institutional healthcare billing with the highest accuracy and expediency. It carries specific insurance claim and reimbursement information – including the name and availability of a patient, the right information about the type and quality of the service, and how much it costs.

6.3 Can the referring and rendering provider be the same?

Often it is the referring provider and the rendering provider, and at times, the referring provider and the rendering provider are one and the same provider/entity (eg, primary care patient practice (referring provider) (rendering provider)). However, it is critical to understand that the referring and rendering providers have created distinct roles in the patient care journey.

6.4 What is the difference between CMS-1500 and UB-04 forms?

The key point of distinction is that the UB-04 is the form used by institutional healthcare providers (eg, hospitals and clinics) whereas the CMS-1500 is the form used by individual providers as the basis for billing their professional services.

read more : Understanding the Distinctions between UB-04 and CMS-1500

6.5 What is a billing provider?

A billing provider processes claims and invoices for reimbursement, making sure that the claims submitted to an insurer or third-party are accurate and timely. A rendering provider is the one who performs the procedure and/or supplies the item. A health care facility is the one who provides the services.


Submission of medical claims can be technical and demanding because there is more than one type of referring provider, ordering provider, rendering provider, and more than one type of claim form (UB-04 vs CMS-1500). This article pointed out the definitions, purpose and difference of these billing providers and claim forms. Hopefully, this detailed medical billing article has provided a more systematic understanding of medical billing and claims for people in the medical industry.