GHA Regulatory Alert

REGULATORY ALERT
TO:
CFOs, CMOs, In-House Counsel, Compliance Officers, and Patient Financial Services Directors
FROM:
Temple Sellers, General Counsel
Keri Conley, Associate General Counsel
DATE:
April 15, 2014
RE:
Medicaid OPR Enrollment Requirement to Become Effective June 1st for All Claim Types
As previously reported by GHA, the Georgia Department of Community Health (DCH) continues to
implement a new federal requirement that all claims for services requiring an order, prescription or
referral under the Medicaid fee-for-service (FFS) program be denied unless the claim contains the
National Provider Identifier (NPI) of an ordering, prescribing or referring (OPR) physician or other
practitioner enrolled in the Medicaid program. This new enrollment requirement became effective for
pharmacy claims on October 1, 2013. DCH has now announced that effective April 1, 2014, it will begin
editing all claims types for the NPI of the OPR provider when an order, prescription or referral is
necessary for Medicaid payment. Hospitals and other providers will be notified through the claims
transaction process if the OPR provider identified on the claim is not enrolled in the Georgia Medicaid
program as either an OPR or participating provider. Effective June 1, 2014, Medicaid FFS claims will be
denied if the OPR provider is not enrolled. The Medicaid Care Management Organizations (CMOs)
have indicated they plan to implement the OPR enrollment requirements effective November 1, 2014.
During the April 1 to June 1 transition period, providers will receive an edit on the remittance advice for
claims that do not meet the new OPR enrollment requirements. The specific edits will appear as
numbers 1802 – 1825 on the remittance advice. Examples of the edit descriptions include:
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COS/Procedure Requires Referring/Ordering/Attending Provider
Provider NPI Not In MMIS
Provider Not Active/Eligible
Provider Cannot Order/Refer/Prescribe
DCH has previously issued FAQs regarding the OPR enrollment requirement and has informed GHA that
it will be issuing an updated version of the FAQs in the near future to reflect the new implementation
dates. However, no other substantive changes to the FAQs are expected. Additional information,
including previous GHA Regulatory Alerts on this topic, is available on the GHA Regulatory Page. GHA
has worked with DCH throughout the implementation process. We have expressed concern to DCH
regarding the impact to teaching hospitals and the ability of resident physicians to write orders for
Medicaid beneficiaries and about the Department’s decision to extend this requirement to claims
submitted to the CMOs, which is not required by the federal law.
Hospitals may wish to consider the following actions to help prepare for the full implementation of the
Medicaid OPR enrollment requirements:
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Issue letters to your medical staff requiring enrollment as either an OPR or Participating
Provider;
Issue letters to providers not on your medical staff and not already enrolled as Participating
Provider in traditional FFS Medicaid, who have historically referred Medicaid patients to your
hospital, encouraging them to enroll as OPR providers;
Issue communications to your academic partners highlighting that residents must write
prescriptions, orders or referrals for traditional FFS Medicaid enrollees using the individual NPI
of their attending or supervising provider (and that provider must be enrolled as a Participating
or OPR Provider in traditional FFS Medicaid); and
Clarify that Fellows with the credentials to independently enroll in Medicaid need to do so to
ensure that their prescriptions, orders and referrals for traditional FFS Medicaid enrollees are
accepted by Participating Providers.
In addition, GHA strongly encourages hospitals to track the number and type of OPR enrollment edits
you receive during the transition period and report any significant concerns to GHA no later than May
15, 2014. Georgia is one of the first states in the country to begin denying claims under this new
requirement, and we need your help in identifying potential issues hospitals may encounter as part of
the implementation process. GHA will continue to work closely with DCH to resolve any such issues.
If you have questions regarding the new Medicaid enrollment requirements, please contact Temple
Sellers at 770-249-4527 or [email protected] or Keri Conley at 770-249-4564 or [email protected].
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