Even if you do not submit claims to Medicaid, you are required to complete OPR provider enrollment if you are an ordering, prescribing, and referring (OPR) provider for Medicaid patients. This requirement was implemented by the Affordable Care Act (ACA) and the Centers for Medicare & Medicaid Services (CMS).
To help you navigate this process, we’ve compiled a list of the most common questions we receive from ordering, prescribing, and referring providers regarding Medicaid enrollment.
OPR Provider Enrollment FAQs
1) Why are OPR providers required to complete Medicaid enrollment?
Additional integrity requirements are placed on state Medicaid programs. This requirement complies with federal regulation 42 CFR 455.410 concerning the screening and enrollment of providers.
2) How do I know if I should enroll as an OPR provider?
This type of enrollment may be suitable for you if:
You occasionally see Medicaid recipients who need additional services/supplies that can be covered by Medicaid.
You do not plan to submit claims to Medicaid for reimbursement.
You are not enrolled as another Medicaid provider type.
3) What are the OPR requirements?
The 3 basic OPR requirements are:
The provider who wrote the order/prescription/referral must be enrolled in Medicaid (either as a participating Medicaid provider or as an OPR provider) and that provider’s NPI must be included on the claim.
The provider’s NPI must be for an individual physician or non-physician practitioner (not an organizational NPI).
The provider must be of a specialty type that is eligible to order, prescribe, or refer.
4) Do I have to be enrolled as a participating provider or can I be enrolled only as an OPR provider?
If you will only be ordering, prescribing, and referring services for Medicaid recipients and won’t be billing Medicaid for these services, you may enroll as only an OPR provider. But if you wish to bill Medicaid, you must enroll as a fully participating Medicaid provider.
OPR providers do not bill Medicaid and are not required to treat Medicaid patients.
5) If I am already enrolled as an active provider with a state’s Medicaid program, do I also need to enroll as an OPR provider in that state?
No; anyone who is an active Medicaid participating provider does not need to enroll again as an OPR provider.
6) Is there a separate Medicaid enrollment application for OPR providers?
Yes; each state has a separate Medicaid enrollment application specifically for OPR provider enrollment.
7) If I am enrolled in one state’s Medicaid program, do I still need to enroll in other states’ programs?
If you order, prescribe, refer, or render services for a Medicaid patient, you must be enrolled in the state program to which the patient belongs. For example, if you are a provider located in California and enrolled in California’s Medicaid program and you write a prescription for an Arizona Medicaid recipient, you must be enrolled in the Arizona Medicaid program as well.
8) What will happen if I fail to complete Medicaid enrollment as an OPR provider?
The healthcare providers and facilities who deliver services according to your orders/prescriptions/referrals will not be reimbursed by Medicaid for those services if you are not enrolled and your NPI is not included on the Medicaid claims they submit.
9) If a claim is denied because the OPR provider is not enrolled in the Medicaid program, can the OPR provider retroactively enroll?
In most cases the billing provider can resubmit the claim after the OPR provider enrolls. There are state-specific claim timely filing limitations.
10) Do claims submitted to Managed Care Organizations (MCOs) have to follow the OPR requirements?
This depends on each MCO or HMO and its specific requirements.
OPR Provider Enrollment Services
EligibilityOne handles all aspects of Medicaid enrollment for both OPR providers and fully participating Medicaid providers, including out-of-state Medicaid enrollment.
If you have more questions regarding OPR provider enrollment or would like EligibilityOne to take care of this process for you, please contact us here.