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 Kipu RCM

The Utilization Plan for U/R-required services and the Attendance Calendar for standalone services reference the referring rendering provider. However, these fields are only available with additional configuration by support. Please reach out to [e-mail] for assistance.

EDI Loop/Segment

Loop 2310A, Segment NM101 (Qualifier), Segment NM103 (Last Name), and NM104 (First Name). For additional information on loops and segments, click here.