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 42 CFR 455.440 - National Provider Identifier
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1. Are attending, rendering, ordering, prescribing or referring providers required to be enrolled in NCTracks?
Attending, rendering, ordering, prescribing and referring providers are required to be enrolled in Medicaid or NC Health Choice if they are included on a claim billed to NCTracks. This requirement also applies to operating, other operating, service facility NPI, assistant surgeon and supervising providers.
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2. What will happen if the attending, rendering, ordering, prescribing or referring provider included on the claim is not enrolled?
If the attending, rendering, ordering, prescribing or referring provider included on the claim is not enrolled in Medicaid or NCHC, the claim will suspend, allowing time for the OPR provider to enroll with NC Medicaid.
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3. How will I know if my claims suspend due to the enrollment of the attending, rendering, ordering, prescribing or referring provider included on the claim?
The Explanation of Benefits (EOB) will indicate the attending, rendering, ordering, prescribing or referring provider included 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 will happen to my claim if an attending, rendering, ordering, prescribing or referring provider included on the claim is not enrolled?
When the claim is billed with non-enrolled provider’s NPI, the claim will suspend for 90 days to allow the non-enrolled provider to enroll in NC Medicaid or NCHC. If, after 90 days from the date of suspension, the attending, rendering, ordering, prescribing or referring provider is not enrolled, the claim will deny.
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5. 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. However, subsequent claims should be submitted with the correct NPI and taxonomy code.
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6. Are attending, rendering, ordering, prescribing or referring providers required to be included on claims?
Please refer to the September 2016 Medicaid Special Bulletin for claim types affected.
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7. What happens if the attending, rendering, ordering, prescribing or referring provider is enrolled after the 90th day claim suspension and the claim denied?
The effective date of the enrollment may not be more than 365 days prior to the date of the enrollment application is submitted. Once the attending, rendering, ordering, prescribing or referring provider is enrolled, the claim can be resubmitted.
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8. Are there any changes related to billing or rendering providers?
As of Feb. 1, 2016, the billing and rendering provider taxonomy code must be valid for the service location billed on the claim. (In the past, the service location simply had to be valid for at least one taxonomy code on the provider record.)
Additionally, effective Aug. 9, 2020, all individual providers (excluding disaster relief and Out-of-State Lite providers) are required to complete the additional questions on enrollment, re-enrollment and re-verification applications on the new Provider Supplemental Information page.
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9. How are psychiatric residential treatment facility (PRTF) claims affected?
Effective July 1, 2015, all institutional claims for PRTF services must include the name and NPI of the recipient’s attending psychiatrist and billing provider for reimbursement. If the attending psychiatrist’s NPI is not entered on the claim, the claim will deny. The attending provider must also submit a psychiatric taxonomy. For more information, refer to the April 2015 Medicaid Bulletin.
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10. What is the effective date of the new enrollment requirements for individual providers?
The additional Provider Supplemental Information questions for individual providers will be required effective Aug. 9, 2020 on enrollment, re-enrollment and re-verification applications. Currently enrolled providers will be required to supply the new information at re-verification, or during re-enrollment if terminated. For a complete overview of the changes, please see the Resources links at the top right of this page.
In addition, certifications and accreditations can be added at any time using the manage change request (MCR) process.
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11. Why are these new enrollment requirements for individual providers being implemented?
Federal regulation 42 CFR 455.410 requires that all ordering, prescribing or referring physicians – as well as other professionals providing services under NC Medicaid, NCHC or their respective waiver programs – be enrolled as participating providers. This includes anyone who orders, prescribes or refers services or items (such as pharmaceuticals) to NC Medicaid and NCHC recipients and seeks reimbursement.
NCTracks is collecting this additional information to assist in streamlining the data collection process for providers and Prepaid Health Plans (PHPs) to facilitate managed care network eligibility determinations.
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12. Where can I find more information about the new individual enrollment requirements?
Please see the June 9, 2020 announcement New Information Required in Applications for Individual Providers Enrolling in Medicaid and NC Health Choice. This communication is also posted as a Medicaid Bulletin posted June 8, 2020 on the DHB webpage.
For the most current updates including resources and training, please check back on the NCTracks website and read NCTracks email updates when available. To subscribe to NCTracks emails, click on the link under the heading “Sign Up for NCTracks Communications” on the NCTracks Provider Communications page or text NCTRACKS to 22828 and follow the prompts.
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13. Will Inpatient Hospital Claims only include the service facility NPI (e.g. hospital's NPI), Outpatient Hospital Clinic Claims only include the service facility NPI (e.g. hospital's NPI) and the referring provider's NPI Outpatient Hospital Clinic Claims with a surgical procedure code only include the operating NPI?
This edit is not being turned on. For more information please refer to the November 2016 Medicaid Bulletin on the 2016 Medicaid Bulletin page.
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14. In the May Special Bulletin, the requirements set forth in the table appear to be inconsistent with Medicare guidelines and the requirements set forth in the Uniform Billing Editor as outlined: Institutional providers are required to report the attending provider name and NPI to identify the provider responsible for the patient's medical care and treatment in FL 76. The only exceptions to this are nonscheduled transportation claims, singular or roster billing of influenza and pneumococcal vaccinations and their administration, or self-referred screening mammography when billed as the only service on a claim. On outpatient claims, institutional providers are required to send the referring provider NPI and name in FLs 78-79 when the referring provider for the services is different than the attending provider.
Providers are to continue to follow NUBC rules for billing. Please note that while the system cannot enforce an NPI to be submitted for situational requirements, if an NPI is submitted the system will validate enrollment with Medicaid.
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15. According to the February 2016 Companion Guide, the Loop 2420E was not mentioned. Since this is the loop for the Ordering Provider, will the companion guide be updated to include that loop?
The Companion Guide will be updated prior to implementation of the change.
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16. Is a taxonomy code required in addition to an NPI number for OPR claims? Example: if a home health agency who is billing Medicaid and providing the referring physician's NPI number, is the taxonomy code also required?
The system may capture the taxonomy if it is submitted. But, it is not displayed on the claim record and is not used in claims processing. The system displays in the claim record the taxonomy for billing, rendering and referring on professional claims and billing and attending on institutional claims. There is no editing around taxonomy except for billing, rendering and attending.
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17. NC State Laboratory of Public Health (NCSLPH) requires the Ordering Provider's NPI and Name to be sent in the claims file, per Medicaid Bulletin published in May 2016 (Attending, Rendering, Ordering, Prescribing or Referring Providers). 1. NCSLPH sends the claims in the 837P file, should we also include the Ordering Provider's Taxonomy in the "2420E" segment of the 8637P file? Please confirm.
According to TR3 Guide for loop 2420E, when Ordering Provider is required to be sent, only the Entity Identifier Code (DK-Ordering Physician), the Entity Type Qualifier (1-person), the Last Name, the City Name and NPI (XX-CMS NPI) are required to be sent. Reference information (Secondary Identification Information) for this loop is situational and is only required if an identification number other than the NPI is necessary for the receiver to identify the provider. The system may capture the taxonomy if it is submitted but it is not displayed on the claim record and is not used in claims processing. The system displays the ordering provider's NPI in the claim record.
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18. Regarding the exception list - Can providers have access to this list?
No, the list is internal to and works within the claims payment logic of NCTracks.
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19. First. What do the terms GME, GDE and AHEC stand for? Second. As we work with major hospitals across the state of pediatric Ventilation discharges, we deal with a lot of residents at the major teaching hospitals. My questions is, if an intern is involved with a major teaching hospital such as UNC Chapel Hill, Duke, Levine's in Charlotte and Wake Forest Baptist in Winston-Salem, would it be safe to assume that most of the resident in these programs are enrolled in the GME, GDE or AHEC training programs?
First. GME - Graduate Medical Education; GDE - Graduate Dental Education; AHEC - Area Health Education Center. Second. Yes, it would be safe to assume that any OPR provider enrolled in a GME, GDE or AHEC training program would be an enrolled provider.
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20. Some of our members expressed confusion over how to reconcile the managed care referral process and the OPR claims edits scheduled to take full effect in November. Does it mean that managed care referrals can be sufficiently handled if the rendering provider's claim includes the PCE's NPI?
The OPR (Ordering, Rendering, Prescribing and Referring) referral requirements and the changes to the Community Care of NC/Carolina (CCNC/CA) ACCESS referral requirements are independent. The referral requirements for OPR are limited to certain claim types, e.g., DME, Therapies, Private Duty Nursing. Claims submitted to NCTracks for a service tagged as an OPR service require the ordering, rendering, prescribing or referring provider's individual NPI. Claims filed using a group NPI for the referring or ordering provider will deny.
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21. If a referral is successfully registered in advance with Medicaid/NCTracks (via portal or otherwise), must the PCP and the rendering specialist still also comply with the requirement that the OPR provider's NPI be included on the respective claims they file later? Put another way, does the fact that a referral is on-record before a claim is submitted change anything as far as OPR edits are concerned?
OPR editing does not apply to specialist’s claims, however, if the specialist chooses to use the referring NPI it must be the individual NPI and not the organization’s NPI.
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22. Will the application form be available in the NCTracks provider portal - Status and Management page?
Yes.
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23. Is there a specific date on which the application form will be available for providers?
We anticipate it will be available in February 2017.
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24. According to June Special Bulletin, Ordering provider segment is going to be mandated in NCSLPH's 837P file starting November 1, 2016. How do we request Ordering Provider's to enroll in NCTracks if the form is going to be available in February 2017? Please let us know how to handle this type of situation.
The streamlined application for Ordering, Rendering and Referring (OPR) providers may be available through NCTracks in February 2017. In the interim, OPR providers may enroll using the existing full Medicaid enrollment application. The application is available online through the secure NCTracks provider portal.
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25. Will providers be notified when the form is made available i.e. in the Medicaid Bulletin, NCTracks communication email, etc.?
Yes.
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26. If the form is only for Ordering/Referring Physicians who do not bill Medicaid for the services provided by them, how will such providers be informed of this application?
Bulletin articles, provider associations, stakeholders meetings, NCTracks provider communications, etc.
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27. Is it mandatory for all providers in NC to fill-out this application form?
No, ONLY those ordering, prescribing and rendering providers who do not intend to file claims. Currently enrolled providers who bill Medicaid and also order, prescribe and refer do not need to complete this application.
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28. Is there a fee associated in filling out this application form?
Yes. Enrollment fees are applicable.
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29. A specialist will not be required to enter the referring Dr in claim box 17b, but if they do, the referring Dr must be an enrolled Medicaid/Healthchoice provider?
Beginning with date of service November 1, 2016, the electronic equivalent field for block 17B of the professional claim must contain an individual ordering/referring provider NPI as required in the September 2016 OPR Special Bulletin. If an NPI is added to “claim box 17B”, then it must be an individual provider NPI that belongs to an active NC Medicaid/NCHC provider.
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30. Is the PCP Referring Dr individual NPI required or can we leave this field blank even though we did follow protocol for the specialist referral?
There is a table in the September 2016 OPR Special Bulletin that identifies when an ordering/referring individual provider NPI is required on claims.
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31. I have a provider in Gastonia that is listed in NC Tracks with his Gastonia practice location and he has credentials at 12 different hospitals. If he provides surgery to 12 different patients at the 12 different hospitals, does he have to have all 12 hospitals listed as locations under his NPI in NCTracks in addition to his office location that he is currently listed in NC Tracks? (Some of these facilities are within a 150 mile radius of the office)
The attending or rendering provider’s record in NCTracks must have the address of the service location for each place they render service. A single Manage Change Request (MCR) can be submitted to add service locations and affiliate to a group or hospital.
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32. Is the OPR reporting for NC Health Choice only or for NC Health Choice, NC Medicaid (traditional) and NC Medicaid Carolina ACCESS? Is it required for all three?
OPR editing will be on all Medicaid and NCHC health plans. Please refer to the September 2016 OPR Special Bulletin chart for claims requiring these data elements.
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33. If we have an MD who sees a patient in the office and provides an x ray and we bill globally for the x ray (x ray and reading), do we report the NPI for the Ordering MD for the x ray but not the office visit or both or none?
Please follow the 837-P and/or the National Uniform Claim Committee (NUCC) Health Insurance Claim Form Reference Instructional Manual for guidance on the use of referring and ordering providers in one visit.
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34. Assume a rendering doc mistypes the NPI of a referring doc on the claim, the edits are triggered, and the claim pends for 90 days. The rendering doc discovers the error and wants to correct. Can the rendering doc file a replacement or corrected claim with the appropriate NPI? Will it adjudicate while the first one is still pending?
Yes the first claim continues to pend, we do not dupe against pending claims. Eventually the pended claim will deny.
It would be corrected by submitting a new day claim. The term remplacement implies an adjustment and you cannot adjust a pended claim.
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35. Starting Nov. 1, Personal Care Services (PCS) and Community Alternatives Program (CAP) claims will need the service facility NPI and address. For PCS or CAP agencies with multiple locations, should Loop 2310C only be used when the PCS or CAP office address is different from the billing address?
DHB will not implement the Service Facility NPI requirement for PCS claims or CAP claims.
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36. 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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37. What are the "certain claim types" that require the NPI #?
See the OPR Special Bulletin: https://files.nc.gov/ncdma/documents/files/SPECIAL_BULLETIN_OPR_2016_09_0.pdf
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38. Is there any possibility for this rule to be based on claim submission date rather than service date?
Our standard is to edit claims based on date of service unless there is a very compelling reason to use date of processing. The system changes have already been implemented and tested based on date of service.
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39. From provider training, NCTracks made a statement that as of Nov. 1, incident to billing becomes obsolete. Is this true?
Yes. Refer to the NCTracks Communications and Updates newsletters and the October 31 reminder on the provider portal.
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40. As a resident or intern, what should I enter in the taxonomy and license number field when I am completing my OPR lite application?
Starting November 1, 2017, residents and interns will use the taxonomy 390200000X for Student Health Care, and will enter “RTL” in the license number field when enrolling as an OPR lite provider.