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Ordering, Prescribing and Referring Provider Requirements

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POSTED IN: EPIC - The Official Newsletter of MOCEP, January/February 2019, MO HealthNet, Opioids,

Reprinted from Missouri Department of Social Services, Provider Bulletin, Volume 41 Number 24

Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require Ordering, Prescribing or Referring (OPR) physicians or other professionals providing services under the state plan or under a waiver of the plan to be enrolled as participating providers with the state Medicaid agency. Federal regulation 42 CFR 455.440 requires all Medicaid claims for payment of items and services that were ordered, prescribed or referred to contain the National Provider Identifier (NPI) of the physician or other professional who ordered, prescribed, or referred the item or service.

To comply with the above requirements, the MO HealthNet Division (MHD) has developed changes in the claims processing system to deny all claims that require an order, prescription or referral from a physician or other licensed health care professional unless that physician or provider has an active enrollment record on file.

Partial system changes were implemented in November 2017, causing claims for Durable Medical Equipment (DME), Home Health, Independent Laboratories, and Radiology (Imaging) providers to deny if the OPR provider’s National Provider Identifier (NPI) was not listed on the claim, and the OPR provider was not actively enrolled with MO HealthNet.

Effective October 14, 2018, the MHD will implement the following additional changes:

  • Drug claims will deny if the prescriber’s NPI is not listed on the claim and if the prescriber is not actively enrolled with MO HealthNet. A bulletin pertaining to drug claims and OPR requirements titled “Providers Billing Drug Claims – Prescribing Provider NPI” was published on September 21, 2018.
  • DME providers must now indicate the NPI of the OPR provider in either the referring or ordering provider field. The OPR provider still must be actively enrolled with the MHD.
  • Home Health providers must now indicate the NPI of the OPR provider in either the referring or attending provider field. The OPR provider still must be actively enrolled with MO HealthNet.
  • Hospital, Mental Hospital, State Institution Long Term Care (LTC), Nursing Home, Private Home-ICF/MF, Rural Health Clinic, and Hospice provider claims will receive a warning message if the attending provider is not listed on the claim or if the attending provider is not actively enrolled with the MHD. At the end of the warning phase, claims will be denied if the attending provider is not listed on the claim or if the attending provider is not actively enrolled with MO HealthNet. It is estimated the warning phaseprovider is not actively enrolled with MO HealthNet. It is estimated the warning phase will end and claims will be denied on or about December 31, 2018.
  • Other claims from providers that do not currently require the NPI of the OPR provider for submission will receive a warning message if the OPR provider is listed on the claim but is not actively enrolled with the MHD. At the end of the warning phase, claims will be denied if the OPR provider is not actively enrolled with the MHD. It is estimated the warning phase will end and claims will be denied on or about December 31, 2018.

The Missouri Medicaid Audit and Compliance Unit (MMAC) provides an OPR Application that can be downloaded or utilized as a fillable PDF form. MMAC’s provider enrollment personnel will expedite all OPR applications received.