Ordering, Prescribing & Referring (OPR) Providers
Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) include provisions requiring additional screening of Medicaid providers to improve the integrity of the Medicaid program and to reduce fraud, waste and abuse. The laws require any ordering, prescribing or referring (OPR)providers to enroll with Medicaid, even if they do not accept Medicaid. MO HealthNet will comply with this law by 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. To address this requirement, a new enrollment status code is being created to identify OPR providers.
The Mo Healthnet Remittance Advice for DME and Laboratory medical claims have contained the following alert when the ordering provider on the claim is not an active enrolled provider.
|N613||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.|
Providers already enrolled with MO HealthNet do not need to enroll again as an OPR provider, however their enrollment status must be active.
Providers who submit orders, prescriptions or referrals for Medicaid participants must have an active enrollment status with MO HealthNet in order for the billing provider’s claim to be approved. Note: Providers who choose to enroll as “OPR only” providers cannot submit claims to MO HealthNet for payment of services rendered. If the provider wishes to be able to submit claims for payment, then he or she must enroll with MO HealthNet as a billing or performing provider. Click on the link below for an OPR provider application form (Word or PDF fillable forms).