Ga. Medicaid Part II Policies & Procedures for Hospice Services, Appendix K

The Affordable Care Act (ACA) requires physicians and other eligible practitioners who order, prescribe and refer

items or services for Medicaid beneficiaries to be enrolled in the Georgia Medicaid Program. As a result, CMS

expanded the claim editing requirements in Section 1833(q) of the Social Security Act and the providers’

definitions in sections 1861-r and 1842(b)(18) C. Therefore, claims for services that are ordered, prescribed, or

referred must indicate who the ordering, prescribing, or referring (OPR) practitioner is. The department will

utilize an enrolled OPR provider identification number for this purpose. Any OPR physicians or other eligible

practitioners who are NOT already enrolled in Medicaid as participating (i.e., billing) providers must enroll

separately as OPR Providers. The National Provider Identifier (NPI) of the OPR Provider must be included on the

claim submitted by the participating, i.e., rendering, provider. If the NPI of the OPR Provider noted on the

Georgia Medicaid claim is associated with a provider who is not enrolled in the Georgia Medicaid program, the

claim cannot be paid.

Effective 4/1/2014, DCH will begin editing claims submitted through the web, EDI and on CMS1500 forms for

the presence of an ordering, referring or prescribing provider as required by program policy. The edit will be

informational until 6/1/2014. Effective 6/1/2014, the ordering, prescribing and referring information will become

a mandatory field and claims that do not contain the information as required by policy will begin to deny.

A. For the NEW CMS-1500 claim form:

Enter qualifiers to indicate if the claim has an ordering, referring, or prescribing provider to the left of the

dotted line in box 17 (Ordering = DK, Referring = DN or Supervising = DQ).

B. For claims entered via the web:

Claims headers were updated to accept ordering or referring Provider ID and name for Dental and

Institutional claims and the referring provider’s name for Professional claims. The claim detail was

updated to accept an ordering or referring provider ID and name. Utilize the “ordering” provider field for

claims that require a prescribing physician.

C. For claims transmitted via EDI:

The 837 D, I, and P companion guides were updated to specifically point out the provider loops that

capture the rendering, ordering, prescribing, referring and service facility provider information that is now

used to transmit OPR information.