Organized Health Care Delivery System Providers

Current federal regulations (42 CFR 455.410) include provisions requiring additional screening of Medicaid providers to improve the integrity of the program and to reduce fraud, waste and abuse.  State Medicaid agencies are now required to enroll certain types of health care providers that were not previously required to be enrolled as Medicaid providers.

Under new federal and state regulations, all claims for items and services submitted to MO HealthNet will be required to contain the National Provider Identifier (NPI) of the health care professional who performed, ordered, prescribed or referred the service.  This includes some, but not all, health care professionals who have historically provided Developmental Disabilities (DD) waiver services as subcontractors for Organized Health Care Delivery System (OHCDS) providers through the Missouri Department of Mental Health (DMH).  Those subcontractors had to meet all applicable provider qualifications to provide waiver services, but did not have to be directly enrolled with MO HealthNet.

The types of waiver services typically provided by those subcontractors and billed through an OHCDS provider are dentistry, durable medical equipment, behavior services, personal assistance, and physical/occupational/speech therapy.  Qualified providers have always had the option to enroll directly with MO HealthNet.

State regulation 13 CSR 65-2.010 outlines which providers must now enroll with the Department of Social Services.  The state regulation requires that “for any person to receive payment from the MO HealthNet program for items or services other than out of state emergency services, the billing providers and the performing providers of such items or services must be enrolled providers on the date the items or services are provided.”

As defined in 13 CSR 65-2.010:

Provider” means billing and performing providers and includes any person that enters into a contract or provider agreement with MMAC for the purpose of providing items and services to Missouri Medicaid participants.  Provider includes ordering and referring physicians, dentists, and non-physician practitioners.

Performing Provider” means a provider or supplier who provides items or services to Medicaid participants, but who does not directly bill to MO HealthNet program for such items or services or does not directly receive payment from the MO HealthNet program for such items or services.  Performing provider also includes referring and/or ordering physicians, dentists, and non-physician practitioners.

Non-Physician Practitioner” means any person other than a physician or dentist that provides medical, dental, or professional items or services such as, but not limited to, nurses, therapists, counselors, social workers, pharmacists, pharmacies, and dental hygienists.  This does not include persons that provide nonmedical support services such as clerical staff, carpenters, janitorial staff, food service workers, home health aides, personal care aides, Adult Day Health Care employees, and Adult Day Care waiver employees, community support workers and case managers, peer specialists, family support workers, family assistance workers, psychosocial rehabilitation workers, detox technicians/aides, personal assistants, non-professional direct care staff and other secondary support services, but does include the organizations that bill for services provided by those persons.

Questions regarding enrolling as an OHCDS provider can be submitted to