CurrentColorado Rocky Mountain Health PlansPolicy OAC 5160-1-17.9

Ordering, Referring, and Prescribing Provider Enrollment and NPI Requirement

This policy requires ordering, referring, or prescribing providers to be enrolled and screened as participating providers with Ohio Medicaid and mandates inclusion of the ordering/referring/prescribing provider's NPI or legal name on claims for payable services that require an order, referral, or prescription.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOrdering, Referring, and Prescribing Provider Enrollment and NPI Requirement

Policy CodePolicy OAC 5160-1-17.9

Change TypeNo material change

Effective Date

Next Review Date

Key ActionEnsure ordering/referring/prescribing providers are screened and enrolled with Ohio Medicaid and include the provider's NPI or legal name on claims for services that require an order, referral, or prescription to avoid denied reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

42 CFR 455.410/455.440Regulatory basis

Many (thousands)Procedure codes referenced

MultipleProvider types

NPI or legal nameClaim requirement

Reimbursement Conditions and Requirements

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Reimbursement criteria tied to ORP enrollment and claim data

Reimbursement for services that require an order, referral, or prescription is contingent on enrollment and claim data for the ordering/referring/prescribing provider (ORP). Covered when ALL of the following are met:

Ordering, referring, or prescribing provider (ORP) must be screened and enrolled as a participating Ohio Medicaid provider.

The claim for a service that requires an order, referral, or prescription includes the ORP's National Provider Identifier (NPI) or the ORP's legal name.

The combination of payee provider type and procedure code (as enumerated in the policy lists) that require ORP reporting are met for the billed service.

For imaging services subject to modifier conditions, when Procedure Modifier Code 1, 2, 3, or 4 equals 'TC' the modifier condition must be present as specified in the policy.

Procedure Codes and Modifier Requirements

Procedure codes requiring ORP — select provider typesmixedCovered

See large enumerated lists in source

Multiple procedure codes listed in the source document. Full enumerated lists should be consulted in the original policy text (thousands of values across multiple code ranges). Examples include extensive CPT/HCPCS lists such as laboratory, imaging, audiology, speech, therapy, and G‑codes.

Modifier requirement

Modifier requirement for certain imaging codesIf Procedure Modifier Code 1 = TC OR Procedure Modifier Code 2 = TC OR Procedure Modifier Code 3 = TC OR Procedure Modifier Code 4 = TC, the ORP requirement applies for the listed procedure codes when billed by the specified provider types.

Enrollment and Claim Submission Requirements

Prior Authorization

Provider enrollment required for ORP

Ordering, referring, or prescribing providers must be screened and enrolled as participating providers with Ohio Medicaid; Medicaid will not pay the rendering provider for services requiring an order, referral, or prescription unless the ordering/referring/prescribing provider is enrolled.

Denial Risk

NPI or legal name must be present on claim

If a claim does not include the ordering/referring/prescribing provider's NPI or legal name, Medicaid reimbursement will be denied for the service.

Key Terms

Ordering/Referring/Prescribing Provider (ORP) — definition and requirements

DefinitionAn Ordering/Referring/Prescribing Provider (ORP) is a physician or other health care professional who orders, prescribes, or refers a client for a health care service; such providers must be enrolled with Ohio Medicaid and identified by NPI or legal name on claims.

Enrollment requirementORPs must be screened and enrolled as participating providers with Ohio Medicaid before services requiring an order/referral/prescription will be paid

Claim data requirementClaims for services requiring an order, referral, or prescription must include the ORP's NPI or legal name or Medicaid reimbursement will be denied

Regulatory basisImplemented to comply with 42 CFR 455.410 (enrollment and screening) and 42 CFR 455.440 (NPI) and Section 6401 of the ACA