Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require Ordering, Prescribing or Referring (OPR) providers to enroll with Medicaid, even if they do not accept Medicaid. In response, MO HealthNet (MHD) began implementing 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.
Effective November 1, 2017, claims for Durable Medical Equipment (DME), Home Health, Independent Laboratories, and Radiology (Imaging) providers will deny unless the OPR provider’s National Provider Identifier (NPI) is listed on the claim, and the OPR provider is actively enrolled with MO HealthNet.
DME providers – The claims system will not recognize referring providers submitted in the Ordering provider field until additional systems work has been completed. Put the NPI of ordering providers in the referring provider field until further notice.
Home Health – The claims system will not recognize referring providers submitted in the attending provider field until additional systems work has been completed. Put the NPI of attending providers in the referring provider field until further notice.
Independent Laboratory – Put the NPI of the referring physician or non-physician practitioner in the referring provider field.
Radiology (Imaging) – Put the NPI of the referring physician or non-physician practitioner in the referring provider field.
In order to assist with this process, the Missouri Medicaid Audit and Compliance Unit (MMAC) provides an OPR Application that can be downloaded (link) or utilized as a fillable PDF form (link).
MMAC’s provider enrollment personnel will expedite all OPR applications received.
For more information please choose “Providers” from the MMAC home page, and then choose “Provider Enrollment” and then choose “Ordering, Prescribing, and Referring” providers.
Please submit any questions to MMAC.ProviderEnrollment@dss.mo.gov