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.