Why referral required for Enrollment
This is being done in order to comply with program integrity provisions of the Affordable Care Act (ACA), specifically section 6401 which is found in the Code of Federal Regulations: 42 CFR § 455.410(b): “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.” As a result, ORP providers will undergo a screening process to improve program integrity and reduce fraud, waste and abuse. This screening process includes a review of federal exclusion lists and other databases that would prohibit an excluded healthcare professional from being associated with Medicare or Medicaid.
What are the requirements for ORP**
There are three basic requirements:
** 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 and their NPI and NAME must be included on claims submitted to the department.
** The provider’s NPI must be for an individual physician or non-physician practitioner (not an organizational NPI).
** The physician or non-physician practitioner must be of a specialty type that is eligible to order, refer, or prescribe.
Does the Ohio Department of Medicaid have a list of provider types that are eligible to be ORP providers**
Currently, the list of eligible OPR 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
