DCH Requirements for Ordering, Prescribing, Referring Physicians To Take Effect on 7.1.2013

The Affordable Care Act (ACA) requires that all physicians or other practitioners who prescribe or order services for Medicaid recipients or who refer Medicaid recipients will have to be enrolled as a Medicaid provider. Services that are rendered based on a referral, order or prescription will be reimbursed only if the ordering, referring or prescribing physician/practitioner is enrolled in the Georgia Medicaid program. The Department of Community Health had announced that Hewlett Packard would begin accepting applications from OPR providers on April 1, 2013 and that the full requirement will take affect for all claims with DOS on July 1, 2013 and later.

DCH has also published an FAQ on the new requirements for Ordering, Referring and Prescribing providers which can be accessed at the following link:

http://dch.georgia.gov/sites/dch.georgia.gov/files/related_files/site_page/OPR_FAQ_03-19-13.pdf

SHP wants to highlight the following FAQs that were included in DCH’s posting:

1. Referrals, Orders & Prescriptions from Out-of-State Providers:

Federal law requires all OPR physicians or other professionals rendering services under the State Plan to be enrolled as providers. The provider that ordered, prescribed, or referred the services must be enrolled in the Medicaid program in which the beneficiary is eligible, in this case Georgia Medicaid. The NPI of the out-of-state OPR provider must be included on the claim for payment to the provider rendering the services ordered, prescribed, or referred. Therefore, a provider outside Georgia who orders, prescribes, or refers services must be enrolled in the Georgia Medicaid program for Georgia Medicaid to pay the claim of the participating provider who actually renders the service. This includes physicians or other professionals employed at hospitals or other health care facilities.

2. CMO Claims (Amerigroup, Peach State Health Plan & WellCare):

This new OPR requirement does not apply to orders, prescriptions or referrals for individuals enrolled in a Medicaid CMO. It is applicable only to the Georgia Fee for Service (FFS) Medicaid Program.

3. How will you be able to tell if an OPR provider is enrolled in Georgia Medicaid:

The Georgia Medicaid Management Information System (GAMMIS) Web Portal at https://www.mmis.georgia.gov/portal/default.aspx will have a search capability so individuals and entities will be able to determine if an OPR provider is enrolled in Georgia Medicaid.

As a reminder, If you are already enrolled as a Medicaid provider, you do not need to also enroll as a Medicaid OPR provider.

However, it will be critical to ensure that when you perform services for Medicaid patients that were ordered, prescribed or referred by another practitioner, that the other practitioner is enrolled as an active or OPR Medicaid practitioner.