Date: July 18, 2019
To: Ambulatory Surgical Treatment Centers; Birth Centers; and Renal Dialysis Facilities
Re: Referring Provider NPI Usage on Outpatient Claims
This notice reiterates to providers claim preparation information related to the Referring Provider on the UB-04 and 837I claim formats.
The UB-04 Data Specifications Manual and the 837I Implementation Guide state that Provider Type Qualifier Code DN and the Referring Provider NPI are required on an outpatient claim only when the Referring Provider is different than the Attending Provider. If it is not required for the claim, providers are instructed not to send Referring Provider information.
If providers do submit Referring Provider information, even if the claim does not require it, HFS will edit those fields to ensure the Referring Provider NPI is valid and that the Referring Provider is an individual and enrolled with HFS.
Claims with dates of service prior to October 1, 2019 will receive the following informational messages, if the Referring Provider NPI does not pass HFS editing:
H74 – Referring NPI Must be an Individual
H78 – Referring NPI is Not Enrolled
Claims with dates of service beginning October 1, 2019 will receive rejections based on those same errors.
Providers not enrolled must go to the IMPACT webpage to start the enrollment process.
Questions regarding this notice may be directed to the Bureau of Hospital and Provider Services at 877-782-5565.