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Unenrolled prescribers: NEW prescriptions written by prescribers not enrolled with Colorado Medicaid will deny beginning 01/01/18.
Colorado Medicaid will not pay for new prescriptions written on, or after, 01/01/2018 if the prescriber is not enrolled with Colorado Medicaid. Refills written prior to 01/01/2018 by unenrolled prescribers will pay until the prescription expires or until there are no remaining refills. Prior Authorizations requested by unenrolled prescribers will not be processed by the call center beginning 01/01/18.
If a prescriber does not wish to enroll with Colorado Medicaid they should begin referring their patients to a prescriber that is enrolled. Patients needing new prescriptions for their medications written on, or after, 01/01/18 must be written by an enrolled prescriber for Colorado Medicaid to pay for and process the claims.
Pharmacy staff members can identify prescriptions filled by an unenrolled prescriber with a current message that is sent back on the pharmacy claim that says, “On 1/01/18 claim denies- MD not enrolled, call DXC to enroll”. Beginning 01/01/18 the message will read, “Prescriber not enrolled. Call DXC, at 844-235-2387, to enroll”.
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:
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.
Please enroll through the Online Provider Enrollment tool. Instructions and more information can be found on the Department’s Provider Enrollment web page.
Hospital emergency room physicians are required to enroll. They are not exempt from the requirement.
Yes, the ACA does not exempt military or VA practitioners from this requirement.
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.
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.
No, the OPR enrollment requirement also applies if Health First Colorado is being billed secondary to commercial insurance.
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.