ClaimRev Support Documentation

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====== Referring Provider Auto-Add ======

Automatically add a referring provider to claims when one is not already present. Optionally filter by CPT codes.

**Applies to:** Professional (837P), Institutional (837I), Dental (837D)

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===== When to Use This =====

  * Medicare or Medicaid requires a referring provider on claims for certain services
  * Your source system doesn't include the referring provider and claims are being rejected
  * You need a default referring provider for specific CPT codes

**Note:** This rule only adds a referring provider if one is **not already present** on the claim. It will never overwrite an existing referring provider.

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===== Fields =====

^ Field ^ Required ^ Description ^
| Start Date | Yes | When this rule becomes active |
| End Date | No | When this rule expires |
| Payer Number | No | Only apply for a specific payer. Blank = all payers |
| CPT Codes | No | Comma-separated CPT codes. Only add the referring provider if the claim contains one of these codes. Blank = all claims |
| Referring NPI | Yes | The referring provider's NPI |
| Referring Last Name | Yes | Last name (or organization name) |
| Referring First Name | No | First name (leave blank for organizations) |
| Entity Type | Yes | **Person** or **Organization** |
| Notes | No | Your reference notes |

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===== Examples =====

=== Example 1: Medicare Referral Requirement ===

Medicare requires a referring provider on physical therapy claims.

^ Field ^ Value ^
| Payer Number | 00882 |
| CPT Codes | 97110,97112,97140,97530 |
| Referring NPI | 1234567890 |
| Referring Last Name | JOHNSON |
| Referring First Name | MICHAEL |
| Entity Type | Person |

=== Example 2: Default Referring for All Claims ===

A payer requires a referring provider on every claim.

^ Field ^ Value ^
| Payer Number | 60054 |
| Referring NPI | 9876543210 |
| Referring Last Name | PRIMARY CARE GROUP |
| Entity Type | Organization |

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===== What Happens on the Claim =====

  - Checks if Loop 2310A (Referring Provider) already exists in the claim
  - If it **does not** exist: creates Loop 2310A with NM1 segment containing the NPI, name, and entity type
  - If it **already exists**: the rule is skipped — existing referring provider is preserved
  - A note is added: "Referring provider auto-added: {name} NPI {npi}"
  - Shows in Applied Validation Modules as "ReferringProviderAutoAddModule"

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