How should I list the name of the ordering/referring provider when submitting my paper and electronic claims?
Box 17 on the CMS 1500 claim form is a crucial field used to identify the referring, ordering, or supervising provider for the services billed. Correctly completing this section is vital for accurate claim processing and to prevent denials. This comprehensive guide provides detailed instructions for Box 17, including provider types, NPI placement, and referral information, directly addressing common questions like ‘how do you fill out block 17 on a cms 1500 claim’ and ensuring your submissions meet regulatory standards.
Understanding Box 17 in CMS 1500 for Paper Claims
When submitting paper claims using the CMS-1500 form (often referred to as HCFA Box 17), Block 17 is where you list information about the referring, ordering, or supervising provider. Based on CMS IOM Publication 100-4, Chapter 1, Section 80.3.2.1.2, providing this information is a conditional requirement. When required for a submitted service, providers must follow specific guidelines for submitting the provider’s name and identifier in Box 17.
Box 17a: Referring/Ordering Provider Name
In Box 17a, you will enter the name of the referring, ordering, or supervising provider. Accurate formatting is paramount:
- Submit the provider’s name in the order of first name then last name.
- Use the provider’s complete name spelled exactly as it appears on the CMS Medicare Ordering and Referring File.
- Include a hyphen in the last name only if the last name is hyphenated on the official CMS file.
- Do not submit middle initials or suffixes such as MD, DO, Jr., etc. This clarification directly addresses the query about ‘initials for referring provider for medical claim’ and professional suffixes.
- Do not submit “Dr.” before the name.
Box 17b: Referring/Ordering/Supervising Provider NPI
Box 17b is designated for the National Provider Identifier (NPI) of the referring, ordering, or supervising provider. The NPI is a 10-digit identification number assigned to healthcare providers in the United States by CMS. It is critical to ensure the NPI entered here corresponds accurately to the provider named in Box 17a.
Provider Qualifiers in Box 17 (DN, DK, DQ)
To the left of the dotted vertical line in Box 17, before the provider’s name, you must include a valid two-character provider qualifier. This qualifier identifies the specific role of the provider. Understanding these qualifiers is key to correctly filling out Block 17 and avoiding denials related to ‘dn referring provider’ or ‘qualifier dq’.
| Qualifier | Description | Typical Use Case & Examples |
|---|---|---|
| DK | Ordering Provider | This qualifier is used for providers who order diagnostic tests, durable medical equipment (DME), or other medical services. For example, a primary care physician (PCP) who orders an MRI for a patient would be listed as the ordering provider with the DK qualifier. This directly answers ‘what is dk in 17 no box in cms 1500 form’. |
| DN | Referring Provider | Used for providers who refer a patient to another provider for consultation or treatment. For instance, if a PCP refers a patient to a cardiologist, the PCP would be the referring provider with the DN qualifier. This helps clarify ‘dn and referring provider’. |
| DQ | Supervising Provider | This qualifier is used when a service is performed by an individual under the direct supervision of another licensed practitioner, who is responsible for the care. An example would be a physician supervising a physician assistant (PA) or nurse practitioner (NP) who performed the service. This addresses ‘qualifier dq’ scenarios. |
Distinguishing Between Ordering and Referring Providers
The distinction between an ‘ordering provider in CMS 1500’ and a referring provider can sometimes be confusing. An ordering provider initiates an order for a service, supply, or medication. A referring provider sends a patient to another healthcare professional for consultation or treatment. While often distinct, it’s possible for a provider to fulfill both roles. For instance, a physician might order a physical therapy evaluation (ordering) and also refer the patient to a specific physical therapist (referring). In such cases, the appropriate qualifier (DK or DN, or potentially both if sequential services) should be used based on the primary action being reported for that specific claim line item. For example, if a PCP orders a lab test, they are the ordering provider. If that same PCP then sends the patient to a specialist for follow-up, they are the referring provider.
Taxonomy Code (TC Code) in Box 17
Regarding ‘block 17 hcfa tc code,’ the Taxonomy Code is a unique alphanumeric code that designates a provider’s classification and specialization. While Box 17 is primarily for the provider’s name and NPI, a taxonomy code (often represented by a qualifier of “ZZ” followed by the taxonomy code) may be required in certain situations by specific payers or for specific services. When required, the taxonomy code is typically placed on line 17a, following the provider’s name, or potentially in the shaded area of Box 17, depending on payer-specific instructions. Always verify payer guidelines for exact placement and necessity.
Referral Numbers vs. Provider Information in CMS 1500
It’s important to differentiate between provider identification in Box 17 and other administrative details. While some users search for ‘referral number in CMS 1500’, it’s crucial to note that referral or authorization numbers are typically entered in Box 23, labeled “Prior Authorization Number” on the CMS 1500 form. Box 17 is exclusively for the referring, ordering, or supervising provider’s demographic and identification details, not for authorization codes.
Electronic Claims: Loops, Segments, and Box 17 Data
For electronic claims submitted via the ANSI X12 837P transaction, the information from Box 17 is transmitted within specific “Loops” and “Segments.” These are structured data components within the electronic data interchange (EDI) format that carry particular pieces of information. For instance:
- Referring Provider Last Name: Loop 2310A or 2420F, NM1/DN, 03
- Referring Provider First Name: Loop 2310A or 2420F, NM1/DN, 04
- Ordering Provider Last Name: Loop 2420E, NM1/DK, 03
- Ordering Provider First Name: Loop 2420E, NM1/DK, 04
Loops are logical groupings of related segments that repeat within a transaction, while Segments are individual lines of data within a loop. For example, Loop 2310A is dedicated to the referring provider. It is critical that the provider’s name (first and last only, no middle initials or suffixes like MD, DO, RPNA) is accurately mapped to these specified electronic fields, mirroring how it appears on the official CMS Ordering and Referring File, to ensure successful electronic submission and processing.
Common Mistakes and Denials Related to CMS 1500 Box 17
Errors in Box 17 are a frequent cause of claim denials. To avoid these common pitfalls, ensure:
- Incorrect Name Format: Always use “First Name Last Name” exactly as it appears on the CMS Medicare Ordering and Referring File. Omitting or adding middle initials, titles (“Dr.”), or suffixes (“MD,” “DO”) will lead to rejections.
- Missing NPI: Failure to include the correct NPI in Box 17b for the identified provider will result in denial, especially for services requiring a referring or ordering physician.
- Inappropriate Qualifiers: Using the wrong qualifier (DK, DN, DQ) for the provider’s role can cause issues. Ensure you select the qualifier that accurately reflects the provider’s involvement in the service. For instance, using “DN” for an ordering provider (DK) is an error.
- Provider Not Enrolled: The referring or ordering provider must be enrolled in Medicare (or the relevant payer) and be in an approved status for their referrals/orders to be valid. Verify provider enrollment status through official channels like the PECOS system.
- Typographical Errors: Simple typos in the provider’s name or NPI can trigger automated rejections. Double-check all entered information.
Consistent adherence to these guidelines for ‘CMS 1500 Box 17a’ and ‘ordering provider in CMS 1500’ will significantly improve claim acceptance rates.
For further official guidance, always refer to the latest publications from CMS.gov.