The Service Providers section provides additional information relating to the claim on the line level. The Service Providers fields are defined by section below:
Rendering Provider Information: This section provides information about the rendering provider on a service line level.
Rendering ProviderRendering Provider
Select the rendering provider from the drop-down menu.
Rendering provider last name or organization name. The rendering provider is the person or company (laboratory or other facility) who provided the care.
Rendering provider first name.
Rendering provider middle name or initial.
Suffix to individual name.
Rendering provider identification.
Provider Taxonomy CodeProvider Taxonomy Code
Code designating the provider type, classification, and specialization of the rendering provider for this claim. The taxonomy can be different for the same provider on different claims.
Secondary IDsSecondary IDs (button)
Rendering provider secondary identifier. Options are:
| 0B | State License Number |
| 1G | Provider UPIN Number. UPINs must be formatted as either X99999 or XXX999. |
| G2 | Provider Commercial Number. This code designates a proprietary provider number for the destination payer identified in the Payer Name loops, Loop ID-2010BB, associated with this claim. This is to be used by all payers including Medicare, Medicaid, Blue Cross, etc. |
| LU | Location Number |
Referring Provider Information: This section provides information about the referring provider on a service line level. This information is required when a claim involves a referral.
Referring Provider Referring Provider
Select the referring provider from the drop-down menu.
Referring provider last name or organization.
Referring provider first name.
Individual middle name of referring provider.
Suffix to individual name.
Referring provider primary identifier.
Secondary IDsSecondary IDs (button)
Referring provider secondary identifier. Options are:
| 0B | State License Number |
| 1G | Provider UPIN Number |
| G2 | Provider Commercial Number |
Additional Referring Provider InfoAdditional Referring Provider Info (button)
Click to add information on an additional referring provider.
Purchased Service Provider Information: This section provides information about the purchased service provider on a service line level.
Purchased Service ProviderPurchased Service Provider
Select the purchased service provider from the drop-down menu.
Entity type qualifier. Options are:
| 1 | Person |
| 2 | Non-Person Entity |
Other payer primary identifier.
Secondary IDsSecondary IDs (button)
Reference identification qualifier. Options are:
| 0B | State License Number |
| 1G | Provider UPIN Number. UPINs must be formatted as either X99999 or XXX999. |
| G2 | Provider Commercial Number. This code designates a proprietary provider number for the destination payer identified in the Payer Name loops, Loop ID-2010BB, associated with this claim. This is to be used by all payers including Medicare, Medicaid, Blue Cross, etc. |
Supervising Provider Information: This section provides information about the supervising provider on a service line level. This information is required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line.
Supervising ProviderSupervising Provider
Select the supervising provider from the drop-down menu.
Individual last name or organizational name of supervising provider.
Individual first name of supervising provider.
Individual middle name of supervising provider.
Suffix to individual name.
Other payer primary identifier.
Secondary IDsSecondary IDs (button)
Supervising provider secondary identifier. Options are:
| 0B | State License Number |
| 1G | Provider UPIN Number |
| G2 | Provider Commercial Number |
| LU | Location Number |
Service Facility Location Information: This section provides information about the service facility location on a service line level. The purpose is to identify specifically where the service was rendered.
Service FacilityService Facility
Select the service facility from the drop-down menu.
Laboratory or Facility NameLaboratory or Facility Name
Individual last name or organizational name where the patient received treatment.
Service Facility NPIService Facility NPI
Laboratory or facility primary identifier.
Address Lines 1 & 2Address Lines 1 & 2
Address information of the service facility.
Laboratory or facility postal zone or zip code. When a user enters a zip code in a zip code field and clicks tab to move to the next field, the city and state fields are automatically generated based on data received from the USPS. Note: This replaces any data already entered in the city/state fields.
Laboratory or facility city name.
Laboratory or facility state or province code.
Code identifying the country of the laboratory or facility.
Subdivision CodeSubdivision Code
Code identifying the country subdivision.
Secondary IDsSecondary IDs (button)
Service facility location secondary identifier. Options are:
| OB | State License Number |
| G2 | Provider Commercial Number |
| LU | Location Number |
Ordering Provider Information: This section provides information about the ordering provider on a service line level. This information is required when the service or supply was ordered by a provider who is different than the rendering provider for this service line.
Ordering ProviderOrdering Provider
Select the ordering provider from the drop-down menu.
Ordering provider last name or organization.
Ordering provider first name.
Individual middle name of ordering provider.
Suffix to individual name.
Ordering provider primary identifier.
Address Lines 1 & 2Address Lines 1 & 2
Ordering provider address information.
Ordering provider city name.
Ordering provider state or province code.
Ordering provider postal zone or zip code. When a user enters a zip code in a zip code field and clicks tab to move to the next field, the city and state fields are automatically generated based on data received from the USPS. Note: This replaces any data already entered in the city/state fields.
Code identifying the country of ordering provider.
Subdivision CodeSubdivision Code
Code identifying the country subdivision.
Ordering provider contact name.
Ordering provider phone number.
Ordering provider phone extension.
Ordering provider fax number.
Ordering provider email address.
Secondary IDsSecondary IDs (button)
Ordering provider secondary identifier. Options are:
| 0B | State License Number |
| 1G | Provider UPIN Number. UPINs must be formatted as either X99999 or XXX999. |
| G2 | Provider Commercial Number. This code designates a proprietary provider number for the destination payer identified in the Payer Name loops, Loop ID-2010BB, associated with this claim. This is to be used by all payers including Medicare, Medicaid, Blue Cross, etc. |
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