Understanding Ohio Medicaid ORP Enrollment Requirements

Why is Ohio Medicaid requiring Ordering, Referring, and Prescribing Providers (ORP Providers) to enroll as Ohio Medicaid providers?

This mandate stems from the program integrity provisions of the Affordable Care Act (ACA), specifically Section 6401. This section is codified in the Code of Federal Regulations: 42 CFR § 455.410(b), which states: “The State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan in the fee-for-service program to be enrolled as participating Medicaid providers.”

The primary goal of this requirement is to enhance program integrity and significantly reduce fraud, waste, and abuse (FWA) within the Medicaid system. By requiring ORP providers to enroll, Ohio Medicaid can conduct crucial screening processes. This includes thoroughly reviewing federal exclusion lists and various other databases to identify healthcare professionals who are prohibited from associating with Medicare or Medicaid due to past misconduct or exclusion. This proactive measure helps prevent issues such as:

• Fraudulent Orders/Referrals: Preventing providers from ordering unnecessary tests or services to generate fraudulent claims.
• Wasteful Practices: Reducing the incidence of medically unjustified referrals or prescriptions that lead to excessive costs.
• Abuse of Services: Ensuring that beneficiaries receive appropriate care from legitimate providers, thereby safeguarding program resources.

This comprehensive approach to ACA 6401 ordering referring prescribing ensures that only qualified and compliant providers are involved in the care of Ohio Medicaid beneficiaries.

Key Ohio Medicaid ORP Enrollment Requirements for Providers

There are three basic requirements for ORP providers:

1. The physician or non-physician practitioner who wrote the order, referral, or prescription must be enrolled as either a Medicaid billing provider or as an ORP-only (non-billing) provider. Their NPI (National Provider Identifier) and name must be accurately included on claims submitted to the department.
2. The provider’s NPI must be for an individual physician or non-physician practitioner, not an organizational NPI. This emphasizes individual accountability and screening.
3. The physician or non-physician practitioner must be of a specialty type that is eligible to order, refer, or prescribe under Ohio Medicaid guidelines.

Understanding these NPI requirements for Medicaid referrals is critical for compliance.

Eligible Provider Types for Ohio Medicaid ORP Enrollment

Does the Ohio Department of Medicaid have a list of provider types that are eligible to be ORP providers?

Currently, the list of eligible ORP Providers includes:

• Licensed Doctors of Medicine/Osteopathy – (Provider Type 20)
• Licensed Doctors of Chiropractic – (Provider Type 27)
• Licensed Doctors of Dental Medicine/Surgery – (Provider Type 30)
• Licensed Doctors of Podiatric Medicine – (Provider Type 36)
• Licensed Doctors of Optometry – (Provider Type 35)
• Licensed Physician Assistants – (Provider Type 24)
• Licensed Nurse Practitioners – (Provider Type 72)
• Licensed Clinical Nurse Specialists – (Provider Type 65)
• Licensed Certified Nurse Midwifes – (Provider Type 71)
• Licensed Clinical Psychologists – (Provider Type 42)

Note: Organizational providers are prohibited from ordering, referring, or prescribing medications.

Practical Steps for Ohio Medicaid ORP Enrollment

For ordering, referring, or prescribing providers who need to enroll with Ohio Medicaid, here are the practical steps you must take. This process is essential for compliance and ensuring your services can be reimbursed through Medicaid.

The first step is to visit the official Ohio Department of Medicaid (ODM) provider enrollment portal. Here, you will find detailed instructions and the necessary application forms.
To begin your enrollment, please visit the Ohio Department of Medicaid Provider Enrollment page.

Generally, the process involves:

1. Accessing the Enrollment Portal: Navigate to the ODM’s provider portal and locate the specific section for ORP provider enrollment.
2. Gathering Required Documentation: This typically includes your individual NPI, professional licenses, and other credentials.
3. Completing the Application: Fill out the online application accurately and completely. Be prepared to provide detailed information about your practice and specialty.
4. Undergoing Screening: Ohio Medicaid will conduct a screening process, which includes verifying your credentials and checking federal exclusion databases.
5. Receiving Confirmation: Once your application is processed and approved, you will receive confirmation of your enrollment as an ORP provider.

Always refer to the official ODM website for the most current and detailed instructions regarding the Medicaid provider enrollment process Ohio.

Consequences of Non-Enrollment for ORP Providers

Non-enrollment as an ORP provider with Ohio Medicaid can lead to significant repercussions for both the ORP provider and the billing provider seeking reimbursement for services. It is crucial to understand these potential consequences:

• Claim Denials: Claims submitted by billing providers that include services ordered, referred, or prescribed by a non-enrolled ORP provider will likely be denied by Ohio Medicaid. This can lead to substantial financial losses.
• Payment Delays: Even if a claim is eventually processed, issues related to non-enrolled ORP providers can cause significant payment delays, impacting cash flow for the billing entity.
• Compliance Issues: Both the ORP provider and the billing provider could face compliance penalties, audits, or further investigations from Ohio Medicaid due to non-adherence to federal and state regulations.
• Inability to Practice: In some cases, persistent non-compliance could impact an ORP provider’s ability to participate in state healthcare programs.

Ensuring timely and correct Ohio Medicaid ORP enrollment requirements is vital to avoid these serious issues.

Out-of-State ORP Providers and Ohio Medicaid

A common question arises regarding out-of-state ORP providers: Are they also required to enroll with Ohio Medicaid if they order, refer, or prescribe services for Ohio Medicaid beneficiaries?

Yes, generally, out-of-state ordering, referring, or prescribing providers are also required to enroll with Ohio Medicaid. The ACA Section 6401 mandate applies to any professional providing services under the State plan, regardless of their physical location, if those services are for Ohio Medicaid beneficiaries. This ensures that all providers influencing the care of Ohio Medicaid recipients are screened for program integrity purposes.

Out-of-state providers must follow the same enrollment process as in-state providers to ensure claims associated with their orders, referrals, or prescriptions are processed successfully. It is always recommended for out-of-state providers to directly contact the Ohio Department of Medicaid for specific guidance if they anticipate serving Ohio Medicaid beneficiaries.

Important Disclaimer and Recommendation

The information provided in this post is for general informational purposes only and does not constitute legal or professional advice. Ohio Medicaid regulations and enrollment requirements are subject to change. It is imperative that all providers verify the latest requirements and eligible provider lists directly on the official Ohio Department of Medicaid website.

For the most current and authoritative information, please visit the official Ohio Department of Medicaid Providers section.

Frequently Asked Questions (FAQ) about Ohio Medicaid ORP Enrollment

What is an ORP Provider?

An ORP (Ordering, Referring, Prescribing) Provider is a healthcare professional who orders services, refers patients to other providers, or prescribes medications for Medicaid beneficiaries. Even if they don’t directly bill Medicaid for their own services, their role in guiding a beneficiary’s care requires them to be enrolled.

What is an NPI and why is it important for ORP enrollment?

NPI stands for National Provider Identifier. It is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). For ORP enrollment, an individual NPI is crucial as it uniquely identifies the ordering, referring, or prescribing professional, allowing Medicaid to track and screen these individuals for program integrity purposes and to process claims correctly. For more information, you can visit the NUCC NPI Registry.

What is ACA Section 6401?

ACA Section 6401, part of the Affordable Care Act, mandates that all providers who order, refer, or prescribe services for Medicaid beneficiaries must be enrolled as participating Medicaid providers. This provision was enacted to enhance program integrity efforts, reduce fraud, waste, and abuse, and ensure that only legitimate providers are involved in the Medicaid program. You can find more details on Medicaid program integrity on the Medicaid.gov Program Integrity page.