Effective: November 1, 2019
Applies to: Hospitals, Mental Health Hospitals, State Institution Long Term Care facilities, Nursing Homes, Private Home-ICF/IDs, Home Health agencies, Rural Health Clinics, and Hospice claims.
All claims submitted to MO HealthNet must have the National Provider Identifier (NPI) on them. All claims must also have the (NPI) of the Ordering, Prescribing, Referring, or Attending (OPRA) physician or other professional on them, and the OPRA professional must be enrolled with MO HealthNet. Claims missing this information will deny effective November 1, 2019.
Background: Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require Ordering, Prescribing, Referring, or Attending (OPRA) 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 (MO HealthNet). 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. In response, MO HealthNet (MHD) began implementing changes in the claims processing system to deny all claims that require an OPRA physician or other licensed health care professional unless that physician or provider is actively enrolled with MO HealthNet and the NPI is included on the claim.
Timeline:
- Effective November 1, 2017, claims for Durable Medical Equipment (DME), Home Health, Independent Laboratories, and Radiology (Imaging) services began denying if the OPRA provider’s National Provider Identifier (NPI) was not listed on the claim, and the OPRA provider was not actively enrolled with MO HealthNet.
- Effective October 14, 2018, all other provider types began receiving a warning message on claims that did not contain the OPRA’s NPI, or if the OPRA provider was not enrolled with MO HealthNet. The warning message is on your remittance advice, and it says, “Attending physician provider/license number missing.”
Effective November 1, 2019, the warning phase will end and claims will deny if the NPI of the OPRA physician or other professional is not listed on the claim and the OPRA provider is not actively enrolled with MO HealthNet. The claim types this affects are Hospitals, Mental Health Hospitals, State Institution Long Term Care facilities, Nursing Homes, Private Home-ICF/IDs, Home Health agencies, Rural Health Clinics, and Hospice agencies.
Also effective November 1, 2019, for provider claim types not required to submit the NPI of an OPRA physician or other professional, but who choose to submit one anyway, claims will deny if the OPRA provider is not actively enrolled with MO HealthNet. If the provider claim types that are not required to submit the NPI of an OPRA provider leave the field blank, the claim will not deny. For example, a dental claim does not require an ordering provider and will not deny if an OPRA is not listed on the claim. However, if the dental claim does list a referring or other OPRA provider, that OPRA provider must be actively enrolled with MO HealthNet or the claim will deny.
MMAC analyzed claims that were submitted over recent months. Some providers that are required to submit the NPI of the Attending physician or other professional have been receiving the warning messages, but continue to submit claims without the NPI.
See the chart below for the provider types and claim types that need to list the NPI of the Attending physician or other professional:
|
PROVIDER |
Attending NPI Required? |
Claim Types Billed |
| Hospitals | Always required | Inpatient
Outpatient Drug |
| Mental Health Hospitals | Always required | Inpatient |
| State Institutions LTC | Always required | Inpatient
NH |
| Nursing Homes | Always required | NH |
| Private Home – ICF/ID | Always required | NH |
| Home Health | Always required | Home Health |
| Rural Health Clinics | Always required | Outpatient
Drug |
| Hospice | Always required | Outpatient |
Provider types affected: Hospitals, Mental Health Hospitals, State Institution Long Term Care Facilities, Nursing Homes, Private Home-ICF/IDs, Home Health agencies, Rural Health Clinics, and Hospice agencies
Please direct any billing or claims questions to the help desk at 573-635-3559.
For information about how to enroll as a non-billing, OPRA provider, please email the Missouri Medicaid Audit & Compliance Enrollment Unit at MMAC.ProviderEnrollment@dss.mo.gov.