UHIN HCFA 1500 Box 17 and 17a Standard

Approved

UHIN STANDARDS COMMITTEE

Version 2

HCFA 1500 Box 17 and 17A Standard

The UHIN HCFA 1500 Box 17 and 17A Standard is compatible with all HIPAA requirements.

Purpose: The purpose of this Standard is to establish a standard approach to reporting referring provider name and identifier number on the HCFA 1500 claim form. This Standard also provides the cross walk to the ASC X12 837 Professional Claim version 4010A.

Applicability: UHIN HCFA 1500 Box 17 and 17a Standard applies to all professional claims.

Details:

1. Box 17, Referring Provider Name, shall contain the full name of the referring provider. It is recommended providers enter LAST NAME, FIRST NAME in their practice management systems if they have only one field for this information.

The Referring Provider Name is out put in Loop 2310A NM103, 04, 05, 07 of the ASC X12 837 Professional Claim version 4010A1.

2. Box 17a, Referring Provider ID, shall contain the referring provider's Unique Provider Identification Number (UPIN). When the National Provider Identifier (NPI) is adopted, Box 17a shall contain the NPI instead of the UPIN.

The Referring Provider Unique Provider Identification Number (UPIN) is out put in Loop 2310A REF02 of the ASC X12 837 Professional Claim version 4010A1.

3. If Box 17a has data, then Box 17 must contain a name.

4. For providers who do not have a UPIN, use the following codes in the indicated circumstances:

INT000 For interns

RES000 For resident

NPP000 For any non-physician practitioner who is State licensed to order clinical diagnostic tests.

RET000 For retired physicians who were not issued a UPIN

VAD000 For Veterans Administration physicians

SLF000 For provider to report the patient is self referred

OTH000 For physicians who do not currently have a UPIN

Source: UB92 Manual

NOTE: Providers should be aware the use of the above codes with commercial payers may affect payment or cause claims/encounters to be pended.

5. Box 23 (Pre-authorization number) should be completed in addition to Box 17A if so required by the payer.

IMPLEMENTATION ISSUES:

1. Boxes 17 and 17a identify the referring physician. Some payers require other information for a valid referral.

2. Payers who do not currently use UPIN to identify referring providers will accept this number and crosswalk it, if necessary, to their proprietary numbering system.

4.  This Standard will be implemented simultaneously with the implementation of the 004010 837 Professional implementation.

5. The 278 004010 Health Care Services Review-Request for Review and Response Transaction will become the standard for referring provider information effective upon UHIN implementations schedule of the 278 transaction.

History: (MM/DD/YY)

Version 1 / Version 2 / A* 1 / A2 / A3 / A4 / A5
ORIGINATION DATE / 01/14/98 / 4/03
APPROVAL DATE / 03/16/99 / 8/4/04
EFFECTIVE DATE / 04/16/99 / 9/4/04

* A = Amendment

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