OSP News

Blue Cross Complete’s Clarification: Claims Submission and Processing Guidelines for Referring Providers

Posted: 12/11/2024

Claims for referring physicians must be submitted with a valid provider type and unique NPI. The referring provider must be an M.D., D.O., physician assistant, nurse practitioner or certified nurse-midwife. The rendering and referring provider cannot have the same NPI. If any of these data elements are missing or invalid, the claim will be denied. 

In the event where the referring and rendering provider are the same, box 17 on the CMS 1500 form (referring provider) is not a required field and may be left blank. 

For more details on claims submission and processing, refer to the Billing & Reimbursement for Professionals, Section 2.3, pages 8-9 of the Medicaid Provider Manual and Section 13, page 91 of the Blue Cross Complete Provider Manual at mibluecrosscomplete.com.

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