Ordering, Prescribing, Rendering or Referring Provider (OPR) FAQs
This page provides answers to Frequently Asked Questions (FAQs) regarding:
Federal Regulation 42 CFR 455.410 - Attending, Rendering, Ordering, Prescribing or Referring Providers, and Federal Regulation and 42 CFR 455.440 - National Provider Identifier
Updated Jan. 17, 2025
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1. Are attending, rendering, ordering, prescribing or referring providers required to be enrolled in NCTracks? Why?
Attending, rendering, ordering, prescribing and referring providers are required to be enrolled in NC Medicaid if they are included on a claim billed to NCTracks. This includes anyone who orders, prescribes or refers services or items (such as pharmaceuticals) to NC Medicaid beneficiaries and seeks reimbursement. This requirement also applies to operating, other operating, service facility, assistant surgeon and supervising providers.
Federal regulation 42 CFR 455.410 requires that all ordering, prescribing or referring physicians be enrolled as participating providers.
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2. What will happen if the attending, ordering, prescribing rendering, or referring provider included on the claim is not enrolled?
If the attending, ordering, prescribing rendering, or referring provider included on the claim is not enrolled in NC Medicaid the claim will suspend for 90 days to allow the non-enrolled provider to enroll in NC Medicaid. If, after 90 days from the date of suspension, the attending, ordering, prescribing rendering, or referring provider is not enrolled, the claim will deny.
Providers may request an effective date up to 365 days retroactive. When a provider has suspended claims, it is vital to choose an effective date on the enrollment application that covers the dates of services on the suspended claims.
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3. How will I know if my claims suspend due to the enrollment status of the attending, ordering, prescribing rendering, or referring provider included on the claim?
The Explanation of Benefits (EOB) message will indicate if the attending, ordering, prescribing rendering, or referring provider on the claim is not enrolled. The Remittance Advice (RA) posts after every checkwrite to the Message Center Inbox of the secure NCTracks Provider Portal.
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4. What if I made a mistake in keying the provider NPI or taxonomy code that causes the claim to suspend? (In other words, there was an error in the NPI or taxonomy code submitted on the claim, but the provider is enrolled.)
No action is required. The claim will suspend and then deny after 90 days. In the meantime, a new claim with the correct provider NPI or taxonomy code can be submitted. Any subsequent claims should be also submitted with the correct NPI and taxonomy code.
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5. What happens if the attending, rendering, ordering, prescribing or referring provider is enrolled after the 90th day claim suspension and the claim denied?
Once the attending, rendering, ordering, prescribing or referring provider is enrolled, the claim can be resubmitted.
Providers may request an effective date up to 365 days retroactive from the date of application submission. If the provider is enrolled, but needs to backdate their enrollment, a Backdate application can be submitted to request an earlier enrollment date, as long as that date is within 365 days of the date of the backdate application. For more information, see the NCTracks Request to Back-Date Enrollment Effective Dates Job Aid located here on the NCTracks public-facing Provider Enrollment webpage.
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6. If a provider does not want to fully enroll and only wants to participate as an OPR provider only, what application should be completed?
The OPR Lite application is appropriate for ordering, prescribing and referring providers who do not intend to file claims. Should the OPR provider wish to become fully enrolled to receive payment for services rendered, they can complete a Manage Change Request (MCR) through the NCTracks secure provider portal.
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7. Is there a fee associated with filling out the OPR Lite application?
Yes. Enrollment fees are applicable. The Federal Fees and NC Enrollment Fees by Year can be found under Quick Links on the NCTracks Enrollment page.
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8. If a rendering physician submits a claim with a mistyped referring physician NPI that triggers edits and pends for 90 days, can the rendering physician submit a corrected claim with the correct NPI? Will the corrected claim adjudicate while the original claim is still pending?
Yes, the original claim will continue to pend, as pending claims are not checked for duplicates. Eventually, the pending claim will be denied. The provider can correct the error with a new claim submission at any time.
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9. Will pended claims process IMMEDIATELY once the enrollment update is completed or will we as billing providers have to request our pended claims process?
The claims recycle automatically every week, so the billing provider does not need to request the pended claims to process after the enrollment update is completed.
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10. Are there certain claim types that require the ordering, prescribing, or referring NPI?
See Federal Regulation Guidelines for Ordering, Prescribing or Referring (OPR) Providers Fact Sheet for more information.