Ordering, Prescribing, Rendering or Referring Provider (OPR) FAQs

Beginning with date of service February 1, 2016, attending, rendering, ordering, prescribing or referring providers are required to be enrolled in Medicaid or NC Health Choice (NCHC) if they are included on a claim billed to NCTracks. This requirement also applies to operating, other operating, service facility NPI, assistant surgeon and supervising providers.

Beginning with date of service, February 1, 2016 DHHS implemented an interim action for any claim from a provider who has an NPI but is not enrolled in Medicaid or NCHC.  If the attending, rendering, ordering, prescribing or referring provider included on the claim is not enrolled in Medicaid or NCHC, the claim will ”pay and report.” Effective November 1, 2016 the edit disposition will change from a “pay and report” status to “suspend” status.  For more information, please refer to the September 2016 Special Bulletin which can be found on the 2016 Medicaid Bulletin page.

An Informational Edit will post on the claim with the disposition set to "pay and report," which means the EOB will still appear on the paper Remittance Advice (RA), but the edit will not cause the claim to deny. The EOB will indicate the attending, rendering, ordering, prescribing or referring provider included on the claim is not enrolled. (This does not guarantee payment. The claim could deny for another reason.) The RA posts after every checkwrite to the Message Center Inbox of the secure NCTracks Provider Portal.

When the claim is billed with non-enrolled provider’s NPI, the claim will suspend for 90 days to allow the non-enrolled provider to enroll in the Medicaid or NCHC.  If, after 90 days from the date of suspension, the attending, rendering, ordering, prescribing or referring provider is not enrolled, the claim will deny.

You will need to notify the provider to complete an enrollment application on NCTracks.

No action is required. However, subsequent claims should be submitted with the correct NPI and taxonomy code.

Effective November 1, 2016, the requirement of the provider’s NPI as a data element will implemented in order to be compliant with 42 CFR 455.440 National Provider Identifier.  The edit disposition will change from “pay and report” to “suspend”.  Please refer to the September 2016 Medicaid Special Bulletin for claim types affected.

Please refer to the September 2016 Medicaid Special Bulletin for claim types affected.

The effective date of the enrollment may not be more than 365 days prior to the date of the enrollment application is submitted.  Once the attending, rendering, ordering, prescribing or referring provider is enrolled, the claim can be resubmitted.

All individual providers (excluding disaster relief and Out-of-State Lite providers) are required to complete the Provider Supplemental Information page on enrollment, re-enrollment, re-verification applications.

DHB ended the NPI Exemption List in NCTracks (which allowed residents and interns enrolled in Graduate Dental and Medical programs and Area Health Education Centers to be exempt from the provider enrollment requirement) on Aug. 31, 2018. Read more in DHB's article.

All individual providers (excluding disaster relief and Out-of-State Lite providers) are required to complete additional questions on the Provider Supplemental Information page on enrollment, re-enrollment and re-verification applications effective Aug. 9, 2020. 

Residents must enter their health care-related work history. When entering their work history, if the enrolling provider is currently a resident or intern, he/she should enter the details of that residency/internship such as:

Job Title: Resident

Company Name: Healthcare Facility XYZ

Start Date:  Date residency/internship began

End Date: 12/31/9999 if still a resident/intern.

As of Feb. 1, 2016, the billing and rendering provider taxonomy code must be valid for the service location billed on the claim. (In the past, the service location simply had to be valid for at least one taxonomy code on the provider record.)

Additionally, effective Aug. 9, 2020, all individual providers (excluding disaster relief and Out-of-State Lite providers) are required to complete the additional questions on enrollment, re-enrollment and re-verification applications on the new Provider Supplemental Information page.

Effective July 1, 2015, all institutional claims for PRTF services must include the name and NPI of the recipient’s attending psychiatrist and billing provider for reimbursement. If the attending psychiatrist’s NPI is not entered on the claim, the claim will deny. The attending provider must also submit a psychiatric taxonomy. For more information, refer to the April 2015 Medicaid Bulletin.

The additional Provider Supplemental Information questions for individual providers will be required effective Aug. 9, 2020 on enrollment, re-enrollment and re-verification applications. Currently enrolled providers will be required to supply the new information at re-verification, or during re-enrollment if terminated. For a complete overview of the changes, please see the Resources links at the top right of this page.

In addition, certifications and accreditations can be added at any time using the manage change request (MCR) process.

Federal regulation 42 CFR 455.410 requires that all ordering, prescribing or referring physicians – as well as other professionals providing services under NC Medicaid, NCHC or their respective waiver programs – be enrolled as participating providers. This includes anyone who orders, prescribes or refers services or items (such as pharmaceuticals) to NC Medicaid and NCHC recipients and seeks reimbursement.

NCTracks is collecting this additional information to assist in streamlining the data collection process for providers and Prepaid Health Plans (PHPs) to facilitate managed care network eligibility determinations. 

Please see the June 9, 2020 announcement New Information Required in Applications for Individual Providers Enrolling in Medicaid and NC Health Choice. This communication is also posted as a Medicaid Bulletin posted June 8, 2020 on the DHB webpage.  

For the most current updates including resources and training, please check back on the NCTracks website and read NCTracks email updates when available. To subscribe to NCTracks emails, click on the link under the heading “Sign Up for NCTracks Communications” on the NCTracks Provider Communications page or text NCTRACKS to 22828 and follow the prompts.

This edit is not being turned on. For more information please refer to the November 2016 Medicaid Bulletin on the 2016 Medicaid Bulletin page.

Providers are to continue to follow NUBC rules for billing.  Please note that while the system cannot enforce an NPI to be submitted for situational requirements, if an NPI is submitted the system will validate enrollment with Medicaid.

The Companion Guide will be updated prior to implementation of the change.

The system may capture the taxonomy if it is submitted. But, it is not displayed on the claim record and is not used in claims processing. The system displays in the claim record the taxonomy for billing, rendering and referring on professional claims and billing and attending on institutional claims. There is no editing around taxonomy except for billing, rendering and attending.

According to TR3 Guide for loop 2420E, when Ordering Provider is required to be sent, only the Entity Identifier Code (DK-Ordering Physician), the Entity Type Qualifier (1-person), the Last Name, the City Name and NPI (XX-CMS NPI) are required to be sent. Reference information (Secondary Identification Information) for this loop is situational and is only required if an identification number other than the NPI is necessary for the receiver to identify the provider. The system may capture the taxonomy if it is submitted but it is not displayed on the claim record and is not used in claims processing. The system displays the ordering provider's NPI in the claim record.

No, the list is internal to and works within the claims payment logic of NCTracks.

First. GME - Graduate Medical Education; GDE - Graduate Dental Education; AHEC - Area Health Education Center.  Second. Yes, it would be safe to assume that any OPR provider enrolled in a GME, GDE or AHEC training program would be an enrolled provider.

The OPR (Ordering, Rendering, Prescribing and Referring) referral requirements and the changes to the Community Care of NC/Carolina (CCNC/CA) ACCESS referral requirements are independent. The referral requirements for OPR are limited to certain claim types, e.g., DME, Therapies, Private Duty Nursing.  Claims submitted to NCTracks for a service tagged as an OPR service require the ordering, rendering, prescribing or referring provider's individual NPI.  Claims filed using a group NPI for the referring or ordering provider will deny.

OPR editing does not apply to specialist’s claims, however, if the specialist chooses to use the referring NPI it must be the individual NPI and not the organization’s NPI.

Yes.

We anticipate it will be available in February 2017.

The streamlined application for Ordering, Rendering and Referring (OPR) providers may be available through NCTracks in February 2017. In the interim, OPR providers may enroll using the existing full Medicaid enrollment application.  The application is available online through the secure NCTracks provider portal.

 

Yes.

Bulletin articles, provider associations, stakeholders meetings, NCTracks provider communications, etc.

No, ONLY those ordering, prescribing and rendering providers who do not intend to file claims. Currently enrolled providers who bill Medicaid and also order, prescribe and refer do not need to complete this application.

Yes. Enrollment fees are applicable.

Beginning with date of service November 1, 2016, the electronic equivalent field for block 17B of the professional claim must contain an individual ordering/referring provider NPI as required in the September 2016 OPR Special Bulletin.  If an NPI is added to “claim box 17B”, then it must be an individual provider NPI that belongs to an active NC Medicaid/NCHC provider.

There is a table in the September 2016 OPR Special Bulletin that identifies when an ordering/referring individual provider NPI is required on claims.

The attending or rendering provider’s record in NCTracks must have the address of the service location for each place they render service. A single Manage Change Request (MCR) can be submitted to add service locations and affiliate to a group or hospital.

OPR editing will be on all Medicaid and NCHC health plans.  Please refer to the September 2016 OPR Special Bulletin chart for claims requiring these data elements.

Please follow the 837-P and/or the National Uniform Claim Committee (NUCC) Health Insurance Claim Form Reference Instructional Manual for guidance on the use of referring and ordering providers in one visit.

Yes the first claim continues to pend, we do not dupe against pending claims.  Eventually the pended claim will deny.

 

It would be corrected by submitting a new day claim.   The term remplacement implies an adjustment and you cannot adjust a pended claim.

DHB will not implement the Service Facility NPI requirement for PCS claims or CAP claims.

The claims recycle automatically every week, so the billing provider does not need to request the pended claims to process after the enrollment update is completed.

See the OPR Special Bulletin: https://files.nc.gov/ncdma/documents/files/SPECIAL_BULLETIN_OPR_2016_09_0.pdf

Our standard is to edit claims based on date of service unless there is a very compelling reason to use date of processing. The system changes have already been implemented and tested based on date of service.

Yes. Refer to the NCTracks Communications and Updates newsletters and the October 31 reminder on the provider portal.

Starting November 1, 2017, residents and interns will use the taxonomy 390200000X for Student Health Care, and will enter “RTL” in the license number field when enrolling as an OPR lite provider.