ORPs must register as such under regulations that took effect at the onset of 2013
As a result of the Patient Protection and Affordable Care Act (ACA), eligible nurse practitioners in California must enroll in Medi-Cal for the sole purpose of ordering, referring or prescribing to Medi-Cal beneficiaries. Effective January 1, 2013, health care providers are required to enroll in Medi-Cal as Ordering/Referring/Prescribing (ORP) providers. ORP providers only order, refer or prescribe to covered beneficiaries, but do not submit claims for their services.
The new federal regulations prompting this change include 42 Code of Federal Regulations (CFR) Section 455.410 (b), which mandates that the “State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the State Plan or under a waiver of the plan to be enrolled as participating providers,” and 42 CFR Section 455.440, which mandates that the “State Medicaid agency must require all claims for payment for items and services that were ordered and referred to contain the national provider identifier (NPI) of the physician or the other professional who ordered or referred such items or services.”
The State of California has enacted laws that conform to the new federal regulations. Welfare and Institutions (W&I) Code, Section 14043.1(b)&(o) requires the enrollment of ORP providers as participating providers in Medi-Cal. Additionally, W&I Code, Section 14043.15(b)(3) requires that the NPI of the ORP provider must be listed on the reimbursement claim form from the provider to whom the ORP referred.
Nurse Practitioners who are already enrolled in Medi-Cal with an individual (Type1) NPI don’t have to enroll as ORP providers. However, those providers who serve Medi-Cal patients but aren’t currently enrolled, or are enrolled in Medi-Cal with only an Organizational (Type 2) NPI, must enroll in Medi-Cal as an ORP provider.
Nurse practitioners who are affected by this new requirement include those who are self-employed, or are employed by federally qualified health centers, rural health clinics, Tribal health clinics, and community clinics.
Failure to enroll as an ORP provider will cause claims from a billing provider (a provider to whom an ORP provider has referred) to be denied. As a result, Medi-Cal beneficiaries may not receive needed items or services if the billing provider refuses to accept prescriptions, orders or referrals from non-enrolled ORP providers. Medi-Cal will provide a grace period for the enrollment of ORP providers, and will not impose an immediate denial of claims. It is anticipated that Medi-Cal will begin denying claims for non-enrolled ORP providers effective January 1, 2014.
Providers can download the Medi-Cal Ordering/Referring/Prescribing Provider Application. For additional information regarding enrollment as an ORP provider, please see the provider bulletin, Medi-Cal Requirement for Ordering/Referring/Prescribing Providers Forms and Procedures, located on the Department of Health Care Services website. For any questions regarding ORP Provider enrollment, providers may phone Medi-Cal, Provider Enrollment Division, at (916) 323-1945, or may e-mail PEDCorr@dhcs.ca.gov.
This article was provided by Provider Enrollment Division (PED) Staff with the Department of Health Care Services.