Question

If a physician practice sends claims directly to a payer and receives payments directly, which of these entities does not need to be additionally reported?

a. Billing Provider
b. Rendering Provider
c. Pay-to Provider
d. Referring Provider

Answer 1

In a scenario where a physician practice directly sends claims and receives payments, the Referring Provider does not need to be reported unless a referral is involved.

Step-by-step explanation:

If a physician practice sends claims directly to a payer and receives payments directly, the entity that does not need to be additionally reported is the Referring Provider. The Billing Provider is required because it identifies who is billing and to whom the payment should be made. The Rendering Provider is the individual who actually performed the service and often needs to be identified. The Pay-to Provider is necessary if the location receiving the payment is different from the billing provider. However, the Referring Provider is only reported if a referral is relevant, such as for specialist services, but if the practice is billing directly for services it provided, a referring provider might not be involved in the scenario.