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Back  RFI # 1502: Require referring provider

Formal vs. Informal Help Informal Formal


Lori Harvey


We are having some strong internal debate as to whether we are out of compliance if we require certain acute care providers to always send in the referring provider loop (NPI and other required data elements) for inpatient and outpatient claims based on specified bill types. If this information is not sent, the claim will be rejected back to the provider. I do not believe that we can make this requirement of our providers based on this statement from the X12N Health Care Claim: Institutional Implementation Guide,

"Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send."

Can you please comment on whether this would or would be a HIPAA violation.


Based on the situational rule the referring provider cannot be sent on inpatient claims or when that provider is the same as the attending provider no matter what type of bill is used. ASC X12 cannot comment on whether or not this is a HIPAA violation. See the disclaimer on the ASC X12 RFI Portal (http://www.x12.org/x12org/subcommittees/x12rfi.cfm).
Submission 1/24/2012
Status Date 3/12/2012
Status F - Final
Primary References
Document 005010X223