NCTracks
Update on Enrollment Criteria for Ordering, Prescribing and Referring Providers
All providers who render services to beneficiaries must be enrolled in N.C. Medicaid or N.C. Health Choice (NCHC). In addition, 42 CFR 455.410 (see link below) requires that all Ordering, Prescribing and Referring (OPR) physicians – as well as other professionals providing services under the N.C. Medicaid, NCHC or their respective waiver programs – be enrolled as participating providers. This includes anyone who orders, refers, or prescribes services or items (such as pharmaceuticals) to N.C. Medicaid and NCHC beneficiaries, and seeks reimbursement. This also includes providers directly contracted with the LME/MCOs.
NOTE: The term “referring” in the context of OPR (ordering, prescribing, referring) does not impact the current procedures or requirements related to Carolina ACCESS referral/authorization.
Any physician or non-physician practitioners who render services, or write orders, prescriptions or referrals, must be enrolled in N.C. Medicaid or NCHC. The National Provider Identifier (NPI) of the rendering/attending provided must be included on all claims for payment.
Beginning Feb. 1, 2016, failure of an OPR provider to enroll in N.C. Medicaid or NCHC will result in a 90-day claim suspension. The billing provider will receive a denial with an EOB stating that the OPR provider is not enrolled.
Institutional, clinical and professional claims will suspend for 90 days if any of the NPIs on the claim are found to be providers who are not enrolled in N.C. Medicaid or NCHC. Providers should ensure that all rendering, ordering, prescribing and referring providers of the services for which they submit Medicaid or NCHC claims are enrolled in those programs.
As a reminder, effective July 1, 2015, all Institutional (UB-04/837-I) claims for Psychiatric Residential Treatment Facility (PRTF) services must include the name and NPI of the beneficiary’s attending psychiatrist and billing provider for reimbursement. If the attending psychiatrist’s NPI is not entered on the claim, the claim will deny with EOB Code 03101, “THE TAXONOMY CODE FOR THE ATTENDING PROVIDER IS MISSING OR INVALID.” For more information, refer to the April 2015 Medicaid Bulletin.
If services are furnished to beneficiaries in another state, the out-of-state providers are required to enroll with N.C. Medicaid or NCHC. Enrollment in another state’s Medicaid program does not exempt a rendering or OPR provider from enrolling with N.C. Medicaid or NCHC. More information for OPR professionals can be found in the article Out-of-State Provider Enrollment in this bulletin, as well as on the N.C. Division of Medical Assistance (DMA) Provider Enrollment web page.
Providers with questions about the NCTracks online enrollment application can contact the CSC Call Center at 1-800-688-6696 (phone); 919-851-4014 (fax) or NCTracksprovider@nctracks.com (email).