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Printed Date: 9/22/2015
Paper Claims — Block 17 of the CMS-1500 Claim Form
Based on CMS IOM Publication 100-4, Chapter 1, Section 22.214.171.124.2, ordering/referring provider information is a conditional requirement. In accordance with the IOM, when ordering/referring provider information is required for a submitted service, Palmetto GBA is requiring providers to submit the ordering/referring provider’s name in Block 17 as follows:
Also include a valid provider qualifier in the space to the left of the dotted vertical line, before the provider’s name, in block 17. Choose the appropriate qualifier to identify the role of the provider.
Failure to submit the first and last name in this order and as the name appears on the CMS Medicare Ordering and Referring File could result in a denial for services that require this information.
On electronic claims, the provider’s name should continue to be submitted in the specified Loops for the ordering/referring provider name:
When submitting electronic claims, it is important to pay special attention to suffixes. Please only include the first and last name as it appears on the ordering and referring file. Middle names (initials) and suffixes (such as M.D., D.O., RPNA, etc.), should not be listed in the ordering/referring fields.
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Last Updated: 03/01/2021