Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require all ordering, prescribing, and referring (OPR) providers to enroll in Medicaid, in order for those providing the services to receive payment. These rules apply even if the OPR providers don’t accept or bill Medicaid themselves. The rules were implemented in order to require additional screening of Medicaid providers to improve the integrity of the Medicaid program and to reduce fraud, waste and abuse. Therefore, when claims are submitted for payment, providers must ensure the ordering, prescribing, or referring provider (if there is one) is enrolled. In the future, if the “OPR” provider is not enrolled, the claims will be denied. Systems work is underway to accomplish this. Some billing providers have already received an informational Explanation of Benefits (“pay but report”) notice informing them that the claims will deny in the future if the “OPR” provider is not enrolled.
In order to address this requirement, a new enrollment status code has been created to identify and accommodate “OPR” providers. Click here to access the new OPR application form.
Providers already enrolled with MO HealthNet as active providers do not need to enroll again as an OPR provider.
If providers choose to enroll as “OPR only”, they cannot submit claims to MO HealthNet for payment of services rendered. If providers wish to submit claims for payment, then they must enroll with MO HealthNet as billing or performing providers.
Again, providers who submit orders, prescriptions or referrals for Medicaid participants must enroll with MO HealthNet in order for the billing provider’s claim to be approved.
Any questions regarding OPR applications or to check to ensure your status is “active” should be sent to MMAC.ProviderEnrollment@dss.mo.gov