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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.5 CMS‑1500 Paper Claim Filing Instructions : 6.5.4 CMS- 1500 Provider Definitions

6.5.4
The following definitions apply to the provider terms used on the CMS-1500 paper claim form:
Referring Provider
The referring provider is the individual who directed the patient for care to the provider that rendered the services being submitted on the claim form.
Examples include, but are not limited to the following:
Ordering Provider
The ordering provider is the individual who requested the services or items listed in Block D of the CMS‑1500 paper claim form.
Examples include, but are not limited to, a provider ordering diagnostic tests, medical equipment, or supplies.
Rendering Provider
The rendering provider is the individual who provided the care to the client. In the case where a substitute provider was used, that individual is considered the rendering provider.
An individual such as a lab technician or radiology technician who performs services in a support role is not considered a rendering provider.
Supervising Provider
The supervising provider is the individual who provided oversight of the rendering provider and the services listed on the CMS-1500 paper claim form.
An example would be the supervision of a resident physician.
Purchased Service Provider
A purchased service provider is an individual or entity that performs a service on a contractual or reassignment basis.
Examples of services include the following:
In the case where a substitute provider is used, that individual is not considered a purchased service provider.

Texas Medicaid & Healthcare Partnership
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