Referring Provider
The Referring Provider is the individual who directed the patient for care to the provider rendering the services being reported. Examples include, but are not limited to, primary care provider referring to a specialist; orthodontist referring to an oral and maxillofacial surgeon; physician referring to a physical therapist; provider referring to a home health agency.
Here is an example of EDI 837 with Referring Provider Segment.
EDI 837 Professional. Version 005010X222A1
Example 3: Outpatient Visit with referring provider
1) Patient is same person as subscriber.
2) Payer is commercial health insurance Company
ISA*00* *00* *ZZ*123123 *01*241232 *210424*0719*^*00501*247181800*1*T*:
GS*HC*123123*241232*20210424*0719*2471818*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210424*0719*CH
NM1*41*2*ABC Submitter*****46*123123
PER*IC*John Mike*TE*1214151617
NM1*40*2*241232*****46*241232
HL*1**20*1
PRV*BI*PXC*208500000X
NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692
N3*3937 Kenwood Place
N4*Orlando*FL*32801
REF*EI*81-3777631
HL*2*1*22*0
SBR*P*18*92291223*AED12342*****ZZ
NM1*IL*1*BAKER*Alyssa****MI*723223232
N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St
N4*HOUSTON*TX*77833
DMG*D8*20201204*M
NM1*PR*2*CIGNA*****PI*81400
N3*PO BOX 660044
N4*DALLAS*TX*75266
CLM*10421*100.00***11:B:1*Y*A*Y*Y*P
HI*ABK:R1013*ABF:E860
NM1*DN*1*Jones*Miller****XX*4124121232
NM1*82*1*Nelson*Romer****XX*1023555349
NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059
N3*6100 W CREEK RD SUITE 35
N4*Independence*OH*44131
LX*1
SV1*HC:99213*50.00*UN*1.00*11**1:2
DTP*472*RD8*20201204-20201204
REF*6R*6001
LX*2
SV1*HC:87070*50.00*UN*1.00*11**1:2
DTP*472*RD8*20201204-20201204
REF*6R*6002
SE*36*0001
GE*1*2471818
IEA*1*247181800
HTML Version
Submitter Information
| Transaction Date | 04/24/2021 |
| Transaction Time (HHMM) | 07:19 |
| EDI Version | 005010X222A1 |
| EDI Transaction set | 837 |
| Submitter Entity | Organization |
| Organization Name | ABC Submitter |
| Contact Name | John Mike |
| Contact Phone | 1214151617 |
| Submitter ID | 123123 |
| Receiver ID | 241232 |
| AuthorizationQualifier | 00 |
| Control Number | 247181800 |
| Usage Indicator | T |
| Acknowledgement Requested | 1 |
Billing Provider
| Entity Type | 2 |
| Last or Organization Name | Get Well Family Clinic LLC |
| Address1 | 3937 Kenwood Place |
| City | Orlando |
| State | FL |
| Zip | 32801 |
| NPI | 1740713692 |
| Tax ID | 81-3777631 |
| Taxonomy Code | 208500000X |
Subscriber information
| Payer Responsbility | P |
| Insured Relationship | 18 |
| Group Number | 92291223 |
| Group Name | AED12342 |
| Claim Filling Indicator | ZZ |
Subscriber Name
| Entity Type | 1 |
| Last or Organization Name | BAKER |
| First Name | Alyssa |
| DOB | 12/04/2020 |
| Gender | M |
| Policy No | 723223232 |
| Address1 | 197800 Atascocita Shores Dr |
| Address2 | 302 12 N. Mcgraw St |
| City | HOUSTON |
| State | TX |
| Zip | 77833 |
Payer
| Name | CIGNA |
| Address1 | PO BOX 660044 |
| City | DALLAS |
| State | TX |
| Zip | 75266 |
| Payer ID | 81400 |
Claim Information
| Claim No | 10421 |
| Billed Amount | 100.00 |
| Claim Type | 1 |
| Provider Sign Indicator | Y |
| Provider Accept Assignment Code | A |
| Benefits Assignment Indicator | Y |
| Release of information | Y |
ICD Information
| ICD Code 1 | R1013 |
| ICD Code 2 | E860 |
Referring Provider
| Last Name | Jones |
| First Name | Miller |
| NPI | 4124121232 |
Rendering Provider
| Entity Type | 1 |
| Last or Organization Name | Nelson |
| First Name | Romer |
| NPI | 1023555349 |
Facility
| Name | Clinic For Pain And Anxiety |
| Address1 | 6100 W CREEK RD SUITE 35 |
| City | Independence |
| State | OH |
| Zip | 44131 |
| NPI | 1396885059 |
| POS | 11 |
Line Item : 1
| Line Item ID | 6001 |
| Procedure Code | 99213 |
| Units Code | UN |
| Units | 1.00 |
| Charges | 50.00 |
| ICD Pointers | 1,2 |
| Service From Date | 12/04/2020 |
| Service To Date | 12/04/2020 |
| POS | 11 |
Line Item : 2
| Line Item ID | 6002 |
| Procedure Code | 87070 |
| Units Code | UN |
| Units | 1.00 |
| Charges | 50.00 |
| ICD Pointers | 1,2 |
| Service From Date | 12/04/2020 |
| Service To Date | 12/04/2020 |
| POS | 11 |
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