Claim edit: Missing claim-level referring provider
Stedi now rejects 837P professional and 837I institutional claims that report a referring provider on a service line but not at the claim level.
What is a referring provider?
The referring provider is the provider who directed the patient to the rendering provider – the one who delivered the care on the claim. For example, a primary care provider may refer a patient to a specialist.
When you submit a claim, you can report the referring provider at two levels: the claim level and the service line level.
The claim-level referring provider applies to every service line on the claim.
Claim-level referring provider
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | referring | NM1-01 (Entity Identifier Code) of Loop 2310A (Referring Provider Name) |
| 837I institutional | referring | NM1-01 (Entity Identifier Code) of Loop 2310F (Referring Provider Name) |
The service-line referring provider applies to a single service line.
Service-line referring provider
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.serviceLines[].referringProvider | NM1-01 (Entity Identifier Code) of Loop 2420F (Referring Provider Name) |
| 837I institutional | claimInformation.serviceLines[].referringProvider | NM1-01 (Entity Identifier Code) of Loop 2420D (Referring Provider Name) |
How the edit works
Per HIPAA standards, a referring provider on a service line acts as an override of the claim-level referring provider for that line. Without a claim-level referring provider, there's nothing to override.
If a claim reports a referring provider on a service line but omits the claim-level referring provider, the payer may reject the claim.
This edit catches the issue before the claim reaches the payer. It prevents payer rejections, which take longer to resolve and delay payment for the provider.
Rejection errors
If you submit a claim using Stedi's Claim Submission API endpoints and the claim fails the edit, you'll get back an error response in real time. The response includes details in the errors array:
{
"errors": [
{
"code": "33",
"description": "Missing Claim-level Referring Provider. When referring provider information is reported at the line-level, referring provider must also be reported at the claim-level. Correct and resubmit.",
"followupAction": "Please Correct and Resubmit"
}
]
}If you submit a claim using SFTP and the claim fails the edit, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will include a related claim status category code, claim status code, entity identifier code, and error message:
STC*A6>562>DN*[DATE]*U*[AMOUNT]******A7>562>DN**Missing Claim-level Referring Provider. When referring provider information is reported at the line-level, referring provider must also be reported at the claim-level. Correct and resubmit.~