Current state and federal regulations (13 CSR 65-2 and 42 CFR § 455.410) require Ordering, Prescribing, or Referring (OPR) 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. 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 such items or services.
Drug claims with a date of service on or after October 14, 2018, will deny unless the prescriber is actively enrolled with MO HealthNet.
All outpatient or medical claims billed using the National Drug Codes (NDC) with the appropriate HCPCS or CPT procedure code for the medication administered must also contain an actively enrolled MO HealthNet prescriber. This includes but is not limited to C-codes, G-codes, J-codes, Q-codes, S-codes and non-VFC vaccination CPT codes. For medications billed on outpatient claims the attending provider is treated as the prescriber and for medical claims the rendering provider is used.
In addition, effective October 14, 2018, MO HealthNet will no longer accept a Drug Enforcement Administration (DEA) number in the “Prescribing Provider ID” field on drug claims. Providers must submit the actively enrolled prescribing provider’s NPI in the “Prescribing Provider ID” field. Claims submitted with a date of service on or after the effective date with a DEA number in the “Prescribing Provider ID” field will deny.
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. Please fax completed applications to (573) 634-3105.
Authorization for emergency medications only may be obtained by contacting Pharmacy and Clinical Services at (573) 751-6963. Prescribers should immediately submit an OPR application to MMAC or a subsequent override authorization may be denied.