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CLAIMS SUBMISSION
For Referring Provider
Enter the Referring Provider’s NPI.
NOTE: A facility ID cannot be used for the Ordering/Referring Provider. In those instances where a service was
ordered by a facility, the NPI of a practitioner at the facility ordering the service must be entered in this field.
If no referral was involved, leave this field blank.
DX Code (Field 19D)
Leave this field blank.
Drug Claims Section: Fields 20 to 20C
The following section applies to drug code claims only.
NDC [National Drug Code] (Field 20)
Leave this field blank.
Unit (Field 20A)
Leave this field blank.
Quantity (Field 20B)
Leave this field blank.
Cost (Field 20C)
Leave this field blank.
Name of Facility Where Services Rendered (Field 21)
This field should be completed only when the Place of Service Code entered in Field 24B is 99 – Other Unlisted Facility.
Address of Facility (Field 21A)
This field should be completed only when the Place of Service Code entered in Field 24B is 99 – Other Unlisted Facility.
NOTE: The address listed in this field does not have to be the facility address. It should be the address where the
service was rendered.
Service Provider Name (Field 22A)
Leave this field blank
CLINICAL SOCIAL WORKER
Version 2010 - 01
11/18/2010
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