guides:claim-rules:referring-provider-auto-add
Table of Contents
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)
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.
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 |
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 |
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”
guides/claim-rules/referring-provider-auto-add.txt · Last modified: by brad.sharp