New Requirement for Providers who Order, Refer, or Prescribe Only

Ohio Medicaid will now require that all claims list the name and the National Provider Identifier (NPI) of the health care professional that ordered, referred or prescribed (ORP) the items or services.  This information is required due to changes in federal and state law.  (See information regarding Ohio Administrative Code [OAC] changes below)  If ORP information is not listed on a claim, the billing Medicaid provider will not receive reimbursement for their services.  

This means that some health care professionals that are not currently enrolled with Ohio Medicaid will need to submit an application.
Online Application
Beginning January, 2014, a shortened enrollment application will be available online for providers who have elected not to enroll as billing providers, but do order, refer or prescribe.   This application will allow these providers to enroll as an Ordering, Prescribing or Referring (ORP) Provider only.   Ohio Medicaid will not make payments to an ORP provider, but will use their NPI number for processing claims for services rendered by a participating Medicaid provider.  This application will be available here.
ORP requirements will go into effect on January 12, 2015

The Ohio Department of Medicaid will begin to deny fee-for-service (FFS) claims for certain billing providers that require, but do not include, both of the following:

  • the ordering, referring, certifying, or prescribing (ORP) provider’s legal name and National Provider Identifier (NPI); and
  • when the ORP provider is not enrolled in Medicaid.

The enforcement will begin for FFS claims submitted from these billing providers with dates of service on or after January 12, 2015.

The 1/12/15 enforcement date does not include pharmacy claims submitted through a point-of-sale vendor.  Enforcement for FFS pharmacy claims submitted through a point-of-sale vendor will begin in the near future.

Providers who are rendering services to Medicaid beneficiaries and bill the Department should ensure that such services are being ordered, referred, certified, or prescribed by an eligible provider who is enrolled in Medicaid.  Eligible providers may enroll as an ORP-only provider (see above under “Online Application”) or as a normal billing provider.  ORP-only providers will have an expedited screening process and not be included in the member-provider directory as an available provider.

See our Questions and Answers for more information.

Changes in Ohio Administrative Rule

OAC 5160-1-17.9 (effective 1/1/2014), “Ordering or referring providers”, has been created in order to comply with new program integrity regulations contained in Section 6401 of the Patient Protection and Affordable Care Act (ACA).  Medicaid is implementing new requirements in accordance with 42 CFR 455.410, “Enrollment and screening of providers,” and 42 CFR 455.440, “National Provider Identifier (NPI).”  Ohio Medicaid will require any ordering, referring, or prescribing providers to be screened and enrolled as participating providers with the Medicaid program.  

The rule states that Medicaid cannot pay the eligible rendering provider for any health care service requiring a referral, order, or prescription from a physician or other health care professional unless the ordering, prescribing, or referring provider is enrolled with Ohio Medicaid.  Furthermore, if a claim fails to include the NPI or the legal name of the physician or health care professional that ordered or prescribed the service, or referred the client for the service, Medicaid reimbursement will not be allowed.  Claims submitted to a managed care organization are specifically exempted from the new requirements.


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