Summary
On the CMS-1500 claim form, three distinct provider roles—referring, ordering, and billing—must be reported correctly to ensure proper claim processing. The referring provider is the practitioner who directed the patient to the service; the ordering provider is the one who officially ordered the service or item; and the billing provider is the entity submitting the claim for reimbursement. Each role has specific boxes (Item 17a/17b for referring/ordering; Item 32a/32b for billing) and requires the proper two-digit qualifier and NPI or other ID to avoid denials and rejections.
Provider Roles Defined
Referring Provider
The referring provider is the practitioner who initiated the referral for a service or item—common in DMEPOS and diagnostic lab claims. Their name and NPI must appear in Item 17b of the CMS-1500, with the qualifier DN (referring provider) on electronic claims, or via the shaded “Other ID” field (17a) with the appropriate two-digit qualifier on paper claims Medicare FCSOMedicare FCSO.
Ordering Provider
The ordering provider issues the formal order for services (e.g., a physician ordering physical therapy). On paper CMS-1500 forms, the ordering provider is also reported in Item 17b (sharing the same fields as referring), using qualifier DK (ordering provider) electronically or the corresponding two-digit qualifier in 17a Medicare FCSOMedicare FCSO.
Billing Provider
The billing provider (or supplier) is the individual or organization submitting the claim and receiving payment. Their NPI goes in Item 33a (or 32a if a service facility), and any “Other ID” (e.g., legacy provider numbers) in Item 33b with a qualifier such as ZZ for taxonomy Noridian MedicareNovitas Solutions.
Where to Report on the CMS-1500
| CMS-1500 Box | Purpose | Field Details |
|---|---|---|
| 17 | Referring/Ordering Provider Name/ID | 17a: “Other ID” with two-digit qualifier (e.g., taxonomy, UPIN) 17b: NPI (10-digit) |
| 32 | Service Facility Location (if applicable) | 32a: NPI of service facility 32b: “Other ID” with qualifier |
| 33 | Billing Provider Name/ID | 33a: Billing provider NPI 33b: “Other ID” with two-digit qualifier (e.g., taxonomy, state lic.) San Francisco Health PlanAnthem. |
- Qualifiers in Box 17a/32b/33b include DN (referring), DK (ordering), and ZZ (taxonomy) on electronic claims; on paper, use the two-digit codes (e.g., ZZ, 1G) in the “Other ID” field Medicare FCSOAnthem.
- Separate Forms are required if multiple referring or ordering providers are reported—one CMS-1500 per provider CMSCMS.
Two-Digit Qualifiers for Paper Claims
When populating the “Other ID” fields (Boxes 17a, 32b, 33b), use these common qualifiers:
| Qualifier | Role / ID Type | Source |
|---|---|---|
| DN | Referring provider (electronic only) | Medicare FCSO |
| DK | Ordering provider (electronic only) | Medicare FCSO |
| ZZ | Provider taxonomy | San Francisco Health PlanAnthem |
| 1G | UPIN (legacy identifier) | Anthem |
| 0B | State license number | Anthem |
| EI | Employer Identification Number (EIN) | Anthem |
| G2 | Commercial billing ID | Anthem |
Best Practices & Common Pitfalls
- Match Ordering/Referring Data: Ensure the provider name and NPI in Item 17 match the documentation (orders or referrals). Mismatches lead to CERT denials Noridian Medicare.
- Leave 17a Blank if Not Used: Item 17a was for UPIN; for NPI reporting, leave 17a blank to avoid rejections Medicare FCSO.
- Use Separate Claims: Submit a separate CMS-1500 when more than one referring or ordering provider is involved; electronic claims group them in loops but paper does not CMS.
- Verify Qualifiers: On paper, confirm you’re using the correct two-digit qualifier; on electronic, use DN/DK and XX for NPI Medicare FCSOAnthem.
Recommended articles
Two-Digit Qualifiers in CMS1500 Form
Explains all the shaded-field qualifiers (Boxes 17a, 24I, 32b, 33b) you’ll reference when discussing “Other ID” entries for referring/ordering/billing providers cms1500claimbilling.com.
CMS-1500 Claim Form: How to Fill Out Correctly – Instruction
A field-by-field walkthrough of the entire 1500 form, perfect for readers who want the full context beyond provider roles cms1500claimbilling.com.
Sample New CMS-1500 Claim Form
Provides a downloadable, annotated sample form—great for illustrating exactly where Boxes 17 and 33 live on the page cms1500claimbilling.com.
Frequently Asked Questions on Provider Billing – CMS 1500
Answers common queries around provider IDs, claim status, and submission rules; linking here anticipates and addresses reader follow-ups cms1500claimbilling.com.
CMS 1500 – UB-04 Form Instruction and Guide
For readers looking to compare institutional (UB-04) vs. professional (CMS-1500) billing, this overarching guide keeps them on-site cms1500claimbilling.com.
Conclusion
Accurate identification of referring, ordering, and billing providers is crucial for CMS-1500 claim acceptance. By placing each provider’s NPI and/or “Other ID” in the correct box with the right qualifier—and submitting separate forms when necessary—you’ll minimize denials, streamline payments, and stay compliant with Medicare rules. For the latest instructions, always refer to the CMS Claims Processing Manual, Chapter 26, and your MAC’s published guidance.