Box 17. - NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

Enter the name (First Name, Middle Initial, Last Name) and credentials of the professional who referred, ordered, or supervised the service(s) or supply(ies) on the claim.

If multiple providers are involved, enter one provider using the following priority order: 1. Referring Provider
2. Ordering Provider
3. Supervising Provider

*Medicare wants a claim per provider if multiple providers are involved. Do not use periods or commas within the name. A hyphen can be used for hyphenated names.

Enter the applicable qualifier to identify which provider is being reported. DN Referring Provider
DK Ordering Provider
DQ Supervising Provider

Enter the qualifier to the left of the vertical, dotted line.
Paper or PrtCap - Provider from the referral data base(*Need to be on 3/26/14 or above): Referring Provider assigned on the case screen & Chk only box to include referral source on claim = DN.
Supervising Provider assigned on the case screen & Chk include referral source & supervising physican = DQ.
Ordering Provider assigned on the service & NO checked boxes = DK Note: If on the printed claims options tab, use assignerd provider as referral source is used, DN will be the qualifier & Prov. PIN's NPI will be used.

Note: Eclipse pulls only the NPI from the 'Referral Sources' for Referring, Ordering or Supervising for paper & PrtCap.

Note: Eclipse pulls the Referring Provider from the 'Billing referral' box on the case screen and the 'DN' qualifier is automatically entered. Must have Include this referral source on claims checked to print. (Also works on PrtCap).

Note: 3/20/14 and above. Eclipse pulls the Supervising Provider from the 'Billing referral' box on the case screen and the 'DQ' qualifier is automatically entered when the 'Supervising physician?' check box is checked on the referral source. Must have Include this referral source on claims checked to print. (Also works on PrtCap).

Note: 5/21/14 and above. Eclipse pulls the Ordering provider from the Ordered by box on the service itself and the 'DK' qualifier is automatically entered. (Also works on PrtCap).

Note: If the same provider is to be used as a referral source and a supervising provider, they MUST be entered in the data base twice. (Doesn't matter what boxes are checked if used as an ordering provider, that takes precidence on the bill).

Note - Texas Workers Comp: Must assign a Referral source on case screen (do NOT assign provider as referral source on printed claims options tab [causes a 1G in 17a]) Need State License & NPI. On Payer, select State Lic as expected ID from Referral source. Need a TX employer on the case screen.