Must Referring Physician be Named on Billing Claim Forms?

Question

Answer

With regard to identifying the referring physician on the claim form, the answer depends on who the payer is. Medicare requires the referring physician's identification on all claim forms. Audiological services that are performed without a physician's referral are not payable by Medicare. Medicaid in many states also requires identification of the referring physician, but this will vary somewhat from state to state. To determine what Medicaid requires in your state, contact your state Medicaid office.

For HMOs and commercial insurers, whether to include the referring physician's information depends on the contract and/or administrative procedures manual for that company. Most HMOs have a centralized database with the following information: patient identification, referring physician, receiving health care provider, service authorization number, authorized procedure code(s), authorized diagnosis code(s), and expiration of authorization. So for HMOs, it may not be necessary to identify the referring physician on the claim form. However, I would advise you to read your contract with that company and/or call the Office of Provider Relations in order to determine what information they want on the claim form.

Bottom line: Medicare - always identify the referring physician;Medicaid - depends on each state's Medicaid program requirements;commercial payers (HMOs and indemnity insurers including PPOs) -company specific therefore you will need to contact each company to verify what is required on the claim form.

Robert C. Fifer, Ph.D. is currently the Director of Audiology and Speech-Language Pathology at the Mailman Center for Child Development, Department of Pediatrics, University of Miami School of Medicine. He received his B.S. degree from the University of Nebraska at Omaha in Speech-Language Pathology with a minor in Deaf Education. His M.A. degree is from Central Michigan University in Audiology. And his Ph.D. degree is from Baylor College of Medicine in Audiology and Bioacoustics. Dr. Fifer's clinical and research interests focus on the areas of auditory evoked potentials, central auditory processing, early detection of hearing loss in children, and auditory anatomy and physiology. He is the immediate Past-President of the Florida Association of Speech-Language Pathologists and Audiologists, a member of ASHA's Health Care Economics Committee, and the ASHA representative to the American Medical Association's Health Care Professions Advisory Committee for the Relative Value Utilization Committee in addition to being ASHA's representative to the AMA's Practice Expense Advisory Committee. Additional responsibilities at the state level include serving as a consultant to the Florida Department of Health's Children's Medical Services and the audiology representative to the Genetics and Newborn Screening Advisory Council.