Rule about Provider Medicaid Enrollment Being Enforced by States

Many states are beginning to implement and enforce a rule, introduced in the Affordable Care Act, that ordering, prescribing and/or referring providers must be enrolled in Medicaid for their medical orders to be recognized and paid for. A number of ASAM members have been notified by their states in the previous months that they may need to enroll in Medicaid in order to have their prescriptions recognized when patients go to the pharmacy. Providers do not have to be listed in Medicaid directories or submit claims to Medicaid for patients, but in order for prescriptions, referrals or orders to be paid for by Medicaid, providers must sign up as Ordering, Prescribing or Referring Providers (OPR Providers). This rule was designed to reduce waste, fraud and abuse by ensuring that prescriptions and other referrals are coming from providers who are not under investigation for fraud, are properly licensed and otherwise allowed to order these services. OPR providers must also submit their National Provider Identifier (NPI) with the ordered service or drug. Claims for prescriptions, orders and referrals will be denied by Medicaid if the referring provider is not enrolled in Medicaid or does not supply their NPI with the referral. These rules only apply when working with Medicaid fee-for-service patients and not risk-based managed-care plans. For more information about these rules, see this FAQ document from CMS. A number of states, including Indiana, Georgia, and Connecticut, have a streamlined enrollment process for physicians and non-physician providers who want to become OPR providers only.  To find information about enrolling, go to your state’s Medicaid website and find the section for providers. Enrollment forms, instructions and phone numbers or email addresses for more information can be found there.