Ambetter Referring Provider Clean Claim Requirements

Date: 07/01/20

As a reminder to diagnostic imaging and laboratory service providers, identification of the referring provider is required for all claim submissions. All diagnostic imaging and laboratory services are referred or ordered by another practitioner or other provider. Therefore, all paper and electronic clean claim receipts must include the name and National Provider Identifier (NPI) of the referring Primary Care Physician (PCP), specialty physician, hospital or other source.

As stipulated in Ambetter from Superior HealthPlan's Provider and Billing Manual, and consistent with the Texas Prompt Pay requirements in the Texas Administrative Code Clean Claim Rules (28 TAC §21.2803 (b) (1) (R-T)), the referring provider is a clean claim element for paper and electronic claims. The clean claim element specifications are included below: 

Paper Claims

• NAME of the referring provider – Field 17, CMS-1500 (02/12) claim form
• NPI of the referring provider – Field 17b, CMS-1500 (02/12) claim form
  • Leave field 17a blank.

Electronic Claims

• 837P 2310A Referring Provider Loop, segment NM101 using qualifier DN, NM103-NM105 [Name], NM108 using [XX] qualifier and NM109 [NPI].
  • No information should appear in 837P 2310A loop, segment REF02.

To ensure compliance with all applicable claims processing requirements and state and federal regulations, effective for claims received July 30, 2020 and after, Ambetter will reject diagnostic imaging and laboratory service claims as ‘unclean’ if the referring provider name and NPI identifiers are missing, invalid or submitted in the wrong item. Re-submission of a completed claim, including the referring provider name and NPI, within 95 days of the date of service will be required for payment consideration of the claim.

Ambetter appreciates your continued participation and provision of services for Health Insurance Marketplace members. For additional information, please contact your assigned Account Manager.