Ordering Prescribing or Referring Providers

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An Overview of the New Medicaid Requirements for Ordering, Prescribing or Referring Providers

Traditionally, most providers have enrolled in Health First Colorado (Colorado’s Medicaid Program) to furnish covered services to Medicaid members and to submit claims for such services. However, the Affordable Care Act (ACA) now requires physicians and other eligible practitioners to enroll in Health First Colorado to order, prescribe and refer items or services for Health First Colorado members, even when they do not submit claims to Health First Colorado.

Physicians and other practitioners who order, prescribe or refer items or services for Health First Colorado members, but who choose not to submit claims to Health First Colorado, are referred to throughout this page as “OPR providers.”

The new enrollment requirement for OPR providers does not include a requirement to see Health First Colorado members or to be listed as a Medicaid provider for patient assignments or referrals.

The ACA requires OPR providers to enroll only to meet new ACA program integrity requirements designed to ensure all orders, prescriptions or referrals for items or services for Health First Colorado members originate from appropriately licensed practitioners who have not been excluded from Medicare or Medicaid.

Physicians and other eligible professionals who are already enrolled in Health First Colorado as participating providers are not required to enroll separately as OPR providers. This requirement applies only to physicians and other eligible practitioners (Audiologists, Certified Registered Nurse Anesthetists, Dentists, Nurse Practitioners, Nurse-Midwives, Optometrists, Osteopaths, Podiatrists, Psychologists - Doctorate level and Speech Therapists) who are OPR providers but are not currently enrolled in Health First Colorado.

It is important for OPR providers to understand the implications of failing to enroll in Health First Colorado. Physicians, other practitioners and facilities who render services to Health First Colorado members based on your order, prescription or referral, will not be paid for such items or services unless you enroll in Health First Colorado and your National Provider Identifier (NPI) number is included on the claim submitted to Health First Colorado.

Enrolling in Health First Colorado as an OPR provider:

  • Does not obligate you to see Health First Colorado members;
  • Does not mean you will be listed as a Health First Colorado provider for patient assignment or referral;
  • Allows you to continue to see Health First Colorado members without billing Health First Colorado if you so choose; and,
  • Helps ensure that your orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. 
Frequently Asked Questions (FAQs)

Why is Health First Colorado requiring these providers to become enrolled?

Health First Colorado is complying with Federal Medicaid Regulations in 42 CFR 455.410(b) which provide that Medicaid must require all ordering or referring physicians or other professionals providing services be enrolled as providers, and  42 CFR 455.440, which provides that Medicaid must require all claims for the payment of items and services that were ordered, referred, and prescribed to include the National Provider Identifier (NPI) of the ordering, referring or prescribing physician or other professional. 

How does the ordering, referring, or prescribing provider enroll as a Health First Colorado provider?

Please enroll through the Online Provider Enrollment tool. Instructions and more information can be found on the Department’s Provider Enrollment web page.  

How does this affect hospital emergency room physicians?

Hospital emergency room physicians are required to enroll.  They are not exempt from the requirement.

Does this requirement extend to Military and Veterans Affairs (VA) practitioners?

Yes, the ACA does not exempt military or VA practitioners from this requirement.

How will this impact Health First Colorado members that cross state lines? 

If services are furnished to a Health First Colorado recipient in another state, the out of state providers are required to enroll with Health First Colorado in order to receive reimbursement.  Likewise, if the out of state provider writes a prescription, orders a service, or refers the patient, then the out of state provider must be enrolled with Health First Colorado. 

What if the provider is enrolled with another state’s Medicaid?  Will the provider need to enroll in all states in which he or she provides service?

Enrollment in another state’s Medicaid program does not exempt a provider from enrolling with Health First Colorado.  Providers are required to enroll in each state where they will provide services or where their order/referral/prescription will be provided.

If Health First Colorado is secondary to a commercial insurance plan, would the claim be accepted without an enrolled ordering, prescribing, or referring provider NPI?

No, the OPR enrollment requirement also applies if Health First Colorado is being billed secondary to commercial insurance.

How do we know the NPI of the physician or other eligible practitioner who wrote the prescription or order?

Prescribing physicians and other eligible practitioners must include their NPIs on any prescription/orders they write, to allow the provider filling the prescription/order to submit a valid claim.

 

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