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.
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 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.
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.