Box 17 - Name of Referring Provider or Other Source

Box Definition

Box 17 identifies the name of the referring provider on the claim. Enter the applicable qualifier to the left of the vertical dotted line to identify which provider is being reported.

• DN - Referring Provider 
• DQ - Supervising Provider
• DK - Ordering Provider

In AveaOffice

Practice Configuration Required

AveaOffice Support must turn on the feature of Rendering Provider if this will be a requirement for claim submission. 

For U/R Required Services

The Referring Rendering Provider is added automatically to the claim form based on the Referring Rendering provider entered on the Utilization Plan. 

Standalone Services

The Referring Rendering provider is selected when adding the standalone service to the Attendance calendar. You'll be prompted to choose the Referring Rendering on the service form in the attendance calendar (see screenshot).

EDI Loop/Segment

Loop 2310A, Segment NM101 (Qualifier), Segment NM103 (Last Name), and NM104 (First Name).