Attention: All Providers Ordering, Prescribing and Referring Providers

As DMA has announced in previous Medicaid Bulletins, effective with date of service November 1, 2016, certain claim types will require an attending, rendering, ordering, prescribing, referring, or operating provider NPI be included on the claim. The edits for attending, rendering and prescribing providers have already been implemented, but the disposition of the edits will change on November 1. For additional details regarding the claim types and specific rules, see the September Special Medicaid Bulletin.

The following rules apply to Attending, Rendering, Ordering, Prescribing, Referring, or Operating Provider NPIs:

  • If an Attending, Rendering, Ordering, Prescribing, Referring, or Operating provider NPI is required for the claim type, the claim will deny if the appropriate provider NPI is not present on the claim
  • The Attending, Rendering, Ordering, Prescribing, Referring, or Operating provider NPI submitted on the claim must be enrolled in Medicaid or N.C. Health Choice (NCHC) or the claim will suspend for 90 days to allow time for the provider to enroll

The following rules apply to Referring and Ordering Provider NPIs:

  • The Referring or Ordering provider must be an individual provider. If a claim is submitted with a group provider NPI in the Referring or Ordering Provider field of the claim, it will deny.

Please note that many of the CCNC/CA PCP NPIs are organizations.  Failure to adhere to the guidance to discontinue billing the NPI of the CCNC/CA PCP organizations in the referring provider field mentioned above will result in claim denials for billing a Referring provider that is not an individual.

Billing providers are encouraged to check the enrollment of the Attending, Rendering, Ordering, Prescribing, Referring or Operating provider prior to rendering service. Billing providers can look up current enrollment information regarding other providers using the Enrolled Practitioner Search Page on the NCTracks Provider Portal. For more information, see the September Special Medicaid Bulletin and the OPR FAQs on the NCTracks Provider Portal.

Certain provider types, such as residents and interns enrolled in Graduate Dental and Medical Programs and Area Health Education Centers, are exempt from these requirements. For guidance regarding these exceptions, see the June Special Medicaid Bulletin.