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 has begun 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.
The Mo Healthnet Remittance Advices for Pharmacy, Durable Medical Equipment (DME), Independent Laboratory medical claims, Imaging medical claims, and Home Health claims contain the following alert when the ordering, prescribing, or referring provider on the claim is not an actively enrolled provider:
|Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corrected, a claim with this ordering provider will not be paid in the future.
In the future, the alert will appear on all institutional claims. Afterward, the claims processing system will begin to deny the affected claims. In order to ensure that future claims are not denied, the ordering, prescribing, or referring providers must be enrolled with MO HealthNet. In order to ease this process, 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.
If you have any questions please contact MMAC.ProviderEnrollment@dss.mo.gov