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.
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 (MHD) began 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.
Effective November 1, 2017, claims for Durable Medical Equipment (DME), Home Health, Independent Laboratories, and Radiology (Imaging) providers will deny unless the OPR provider’s National Provider Identifier (NPI) is listed on the claim, and the OPR provider is actively enrolled with MO HealthNet.
DME providers – The claims system will not recognize referring providers submitted in the Ordering provider field until additional systems work has been completed. Put the NPI of ordering providers in the referring provider field until further notice.
Home Health – The claims system will not recognize referring providers submitted in the attending provider field until additional systems work has been completed. Put the NPI of attending providers in the referring provider field until further notice.
Independent Laboratory – Put the NPI of the referring physician or non-physician practitioner in the referring provider field.
Radiology (Imaging) – Put the NPI of the referring physician or non-physician practitioner in the referring provider field.
In order to assist with this process, 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.
For more information please choose “Providers” from the MMAC home page, and then choose “Provider Enrollment” and then choose “Ordering, Prescribing, and Referring” providers.
Please submit any questions to MMAC.ProviderEnrollment@dss.mo.gov
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 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:
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.In November 2017, the claims will begin to deny unless the ordering, prescribing, or referring provider information is on the claim, and the provider is enrolled with MO HealthNet.
In order to assist with this process, the Missouri Medicaid Audit and Compliance Unit (MMAC) provides an Ordering Prescribing and Referring Enrollment Application [OPR]
MMAC’s provider enrollment personnel will expedite all OPR applications received.
For more information, please choose “Providers” from the MMAC home page, and then choose “Provider Enrollment” and then choose “Ordering, Prescribing and Referring Enrollment Application [OPR]” providers.
Please submit any questions to MMAC.ProviderEnrollment@dss.mo.gov
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:
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.
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
Ordering, Prescribing, and Referring (OPR) Provider Application. MMAC’s provider enrollment personnel will expedite all OPR applications received.
If you have any questions please contact MMAC.ProviderEnrollment@dss.mo.gov
