Definition
A referring provider is the practitioner who directed a patient to another provider for a service. The name goes in item 17 of the CMS-1500, with the National Provider Identifier (NPI) in item 17b. Health maintenance organization (HMO) plans often require a referral on file before a specialist visit.
Why it matters
Missing or invalid referring provider data can deny imaging, lab, and specialist claims. For many Medicare services, the ordering or referring provider must be eligible to order or refer in PECOS, or the claim denies. Some plans also require a referral number on the claim.
Example
A specialist sees an HMO member without the referral from the primary care physician. The claim denies, even though the visit itself was a covered service.