Referring providers play a critical role in healthcare billing and coding—especially in 2025, as payer rules and documentation standards continue to evolve. On the CMS-1500 claim form, their name goes in Box 17 and their NPI in Box 17b, with the qualifier “DN.” Getting this right is essential for clean claims and timely reimbursement.
This guide breaks down who qualifies as a referring provider, how to report them correctly, and what’s new for 2025—including Medicare updates and private payer policies. Read on for expert tips to avoid denials and improve billing accuracy.
What Is a Referring Provider?
A referring provider is a clinician who directs a patient to another provider or orders specific services. For example, a primary care physician (PCP) sending a patient to a cardiologist is a referring provider. Similarly, a physician who orders an X-ray is considered the ordering provider.
Under Medicare rules, all ordering or referring providers must be listed on the claim. Their information is required on both CMS-1500 and UB-04 forms, depending on the setting.
Who Can Be a Referring Provider?
Not every healthcare professional can serve as a referring provider. To qualify under Medicare, a provider must:
- Have an individual National Provider Identifier (NPI)
- Be actively enrolled in Medicare
- Belong to a recognized provider type
Eligible types include MDs, DOs, dentists, podiatrists, optometrists (limited scope), PAs, NPs, clinical nurse specialists, certified nurse midwives, clinical psychologists, and clinical social workers.
Make sure the referring provider’s name and NPI match the Medicare enrollment record exactly. Even small discrepancies can lead to denials.
How to Report Referring Providers on Claims
When filling out the CMS-1500 claim form, follow these steps:
- Box 17: Enter the provider’s last name and first initial (omit credentials).
- Qualifier: Use “DN” for referring, “DK” for ordering, or “DQ” for supervising provider.
- Box 17b: Enter the provider’s 10-digit NPI (no dashes).
On the UB-04 form, enter the referring or ordering provider in the “Other Physician” fields. Always follow payer-specific guidance.
Medicare Denials and Edits
Since 2013, Medicare has enforced edits that deny claims if the referring provider isn’t properly enrolled. These edits apply to services like DME, lab tests, imaging, and therapy. Common denial triggers include:
- Incorrect or outdated NPI
- Unrecognized provider type
- Spelling mismatches
- Missing or wrong qualifiers
Use tools like PECOS or CMS’s ordering/referring files to verify enrollment before submitting claims. For additional help, check our denial code troubleshooting guide.
2025 Medicare Update: Therapy Certification Rule
New in 2025, CMS allows outpatient PT, OT, and SLP services to proceed without a signed plan of care—if the referring provider’s signed order is on file and the plan is sent to them within 30 days. If the provider takes no further action, the plan is automatically certified.
This change reduces administrative delays and improves claim turnaround for therapy providers.
Referrals and Private Payers
Private insurers may have stricter referral rules than Medicare. Many HMO and PPO plans require a PCP referral for specialist services. For instance, UnitedHealthcare mandates referrals for certain plans.
Always verify referral requirements with the payer before the service. Missing documentation can result in denials or reduced reimbursement.
2025 Billing Tips
- Verify enrollment: Use PECOS to ensure the provider is actively enrolled and eligible to refer or order services.
- Use accurate qualifiers: “DN” for referring, “DK” for ordering. Incorrect codes will trigger denials.
- Match provider data: Ensure the NPI and name match CMS records exactly.
- Track timelines: For therapy, document when the plan of care was sent to the provider.
- Monitor denial trends: Keep an eye out for recurring issues tied to referring provider fields.
Check out our guide to CMS-1500 Box 17 for detailed examples and best practices.
FAQ
What’s the difference between a referring and ordering provider?
A referring provider directs a patient to another provider. An ordering provider authorizes specific tests or services. Use “DN” for referring and “DK” for ordering on claims.
Can any provider make referrals?
No. Only certain provider types enrolled in Medicare are allowed to refer or order services. Always verify eligibility in advance.
What if the NPI is incorrect?
The claim may be denied. Verify provider data using PECOS or CMS files before submission to avoid errors.
Conclusion
Referring provider details are critical to accurate billing in 2025. From Medicare enrollment rules to payer-specific referral policies, understanding these requirements helps prevent denials and streamline claim processing. Stay updated, follow the latest rules, and visit cms1500claimbilling.com for expert tips and billing support.