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    Attending Providers on Institutional Claims


    Ordering, Referring, & Prescribing (ORP) Practitioners


    Medicaid is federally required to enroll ORP practitioners as participating providers for services billable to the Medicaid program. Specific service and provider types require billing with an ORP practitioner listed on the claim. If a claim includes an ORP provider, that provider must be an individual practitioner who is actively enrolled in the Medicaid program (42 CFR § 455.410). The ORP enrollment requirement includes attending providers on institutional claims. The Medicaid Provider Verification System (PVS) enables providers who bill services that have been ordered or referred (e.g. labs, diagnostic, DME/DMS providers) to determine whether the ORP provider is an actively enrolled individual on the date of service prior to providing the service to a Medicaid participant.


    For general and provider type-specific ePREP enrollment instructions, please visit [ePREP resources page].



    Attending Providers


    All institutional claims submitted to Maryland Medicaid must include the NPI of an attending physician who is enrolled and in an active status as a Maryland Medicaid Provider.

    Impacted Billing Providers

    Provider types subject to the Attending Provider requirements include:

    • Hospitals (PT 01, 03, 04, 05, 06, 07)

    • Home Health Agencies (PT 41)

    • Intermediate Care Facilities – Addiction (PT 55)

    • Intermediate Care Facilities – Intellectual Disabilities (PT 56)

    • Nursing Facilities (PT 57)

    • Dialysis Facilities (PT 61)

    • Residential Treatment Centers (PT 88)

    Background

    The Affordable Care Act and federal regulations require the State Medicaid Agency to enroll ordering and referring providers. The Centers for Medicare and Medicaid Services (CMS) interprets this enrollment requirement to include attending physicians supervising care in institutional settings, including hospitals, nursing facilities and residential treatment centers.  For such services, the attending physician serves as the ORP provider, and must be enrolled with the state Medicaid program for the service to be reimbursed by Medicaid.

     

    Frequently Asked Questions 

     

    Where does this policy come from, and why does it exist? 

    The Affordable Care Act and federal regulations require the State Medicaid Agency to enroll ordering and referring providers. CMS interprets this rule as applying to attending providers in institutional facilities. 

     

    How does an attending provider enroll, revalidate, or update a license with Maryland Medicaid? 

    Attending providers must enroll and update their accounts using ePREP

     

    How can a facility find out whether or not our attending providers are enrolled? 

    Facilities may check attending provider enrollment status using the Provider Verification System (PVS)

     

    If a claim is denied, will Medicaid backdate our attending providers’ enrollment?

    No. Medicaid will only honor backdate requests due to a known technical issue or extenuating circumstance. Failure to enroll providers by the deadline is not sufficient reason to backdate enrollment. 

     

    Can a group practice be the attending provider? 

    No. Attending providers must be individual practitioners with a Type 1 (individual) NPI.

    Requirements

    Institutional claims will be denied if they do not meet all of the following criteria:

    • The attending NPI must be in field 76 on the 837i electronic form or UB-04 paper form. 

      • UB-04 paper claims must also include the Attending Provider’s 9-digit Maryland Medicaid Provider Number in the Secondary Identifier Qualifier field (next to the NPI).

    • The attending provider NPI field must be filled with a valid 10-digit number.

    • The attending provider NPI must belong to a provider who is actively enrolled in the Maryland Medicaid program.

    • The attending provider NPI must be a Type 1 (Individual) NPI belonging to an individual practitioner. A Type 2 (Organizational) NPI belonging to a professional group or facility is not permitted in the attending field.

    If you have any questions please email mdh.providerenrollment@maryland.gov. 

    Resources

    PT 14-19 Attending Providers on Institutional Claims​

    UB-04 Billing I​nstruct​ions​

    UB-04 Form Example (Highlighted Attending Field)​

     



    Referring Providers for Early Intervention and School Health-Related (IEP/IFSP) Services 


    Maryland Medicaid requires local education agencies, local lead agencies, and nonpublic schools to include the NPI of an enrolled referring provider on Medicaid claims.  Referring providers must be actively with Maryland Medicaid for services billable to Medicaid under early intervention and school health-related services provided in accordance with an Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP). 


    Medicaid will deny claims from local education agencies, local lead agencies, and nonpublic schools that do not include a referring practitioner NPI. The NPI must belong to an actively enrolled Maryland Medicaid individual practitioner, and the NPI cannot be a dummy or placeholder NPI. Claims will not be reimbursable if the referring practitioner NPI belongs to a group or facility. All services with the exception of service coordination and transportation require a referring provider’s NPI. 


    Resources


    Ordering and Referring Providers


    Effective for dates of services beginning September 1, 2022, Maryland Medicaid has implemented billing requirements to comply with federal regulations regarding ordering and referring practitioners on professional claims. Maryland Medicaid will require that all claims from certain provider types include the National Provider Identifier (NPI) of an actively enrolled individual practitioner. 


    Impacted Billing Providers


    Provider types that must include the referring practitioner NPI for ordered and referred services:


    • Diagnostic Services (60)

    • Durable Medical Equipment/Disposable Medical Supply (DME/DMS) (62)

    • Labs (Type 10)

    • Portable X-Ray (59)

    • Private Duty Nursing (53)


    Medicaid will deny any claims from these provider types that do not include a referring practitioner NPI. The NPI must belong to an actively enrolled Maryland Medicaid individual practitioner, and the NPI cannot be a dummy or placeholder NPI. Claims will not be reimbursable if the referring practitioner NPI belongs to a group or facility.


    Maryland Medicaid strongly encourages providers to prepare for this change by updating their billing practices to include an active ORP practitioner NPI on claims prior to these edits taking place. Providers can verify the ORP practitioner’s enrollment status using the department's Provider Verification System (PVS).



    Resources


    To enroll ORP practitioners, please submit an application through Maryland Medicaid’s electronic Provider Revalidation and Enrollment Portal (ePREP) by visiting ePREP.health.maryland.gov. Please visit health.maryland.gov/eprep for enrollment instructions ​or contact the ePREP call center at (844)-463-7768. 


    Ordering and Referring Practitioner Enrollment Policy Memos 

    PT-10 Labs 

    PT-53 Private Duty Nursing 

    PT-59 X-Ray 

    PT-60 Diagnostic Services 

    PT-62 Durable Medical Equipment/Disposable Medical Supply (DME/DMS) 


     

    Ordering and Referring Practitioner Enrollment Webinar (Recorded) (07/25/2022)

    Ordering and Referring Practitioner Enrollment Webinar (Slides)


    Referring Provider NPI submissions via Electronic Data Interchange (EDI) (10/14/2022)​

    Prescribing Providers


    All practitioners who prescribe to Maryland Medical Assistance participants must be actively enrolled Medicaid providers under the federal ORP requirements. This requirement applies to both fully licensed practitioners, and medical trainees such as interns and unlicensed residents who prescribe to Medicaid covered patients. Failure to enroll will result in Medicaid patients’ inability to receive needed prescription drugs. Maryland Medicaid is in the planning process of completing implementation of this requirement and will provide further guidance as it becomes available. Any practitioners prescribing to Medicaid participants who are not actively enrolled Medicaid providers should enroll as soon as possible.


    Prescribers who are not fully licensed (interns, unlicensed residents, and medical trainees) must enroll with the Medicaid program as ORP-only providers (Prescribing Provider - PT Code 92) in order for Medicaid to continue to reimburse pharmacies for their prescribed drugs. Fully licensed practitioners may choose to enroll as either a fully participating Medicaid provider or an ORP-only provider. However, only practitioners enrolled as fully participating Medicaid providers may render reimbursable services to Medicaid participants. ORP-only providers cannot receive any payments from Maryland Medicaid.

    Enrollment for purposes of prescribing medication does not require providers to provide services to additional Medicaid participants. If prescribers do not wish to enroll as either fully participating Medicaid providers or ORP-only providers, the Medicaid Program asks that prescribers coordinate with their Medicaid patients to find a practitioner who is enrolled in the Medicaid Program. For assistance directing patients to an enrolled provider, contact the Maryland Medicaid participant's HealthChoice managed care organization or the HealthChoice Enrollee Helpline at 1-800-284-4510.

    Providers may check their current Maryland Medicaid enrollment status using the Provider Verification System (PVS).  

    To enroll, please visit the Maryland Medicaid’s Electronic Provider Revalidation and Enrollment Portal (ePREP) at eprep.health.maryland.gov. Please visit health.maryland.gov/eprep for more information about enrollment requirements and instructions.

    For questions about prescriber enrollment requirements, please email mdh.rxenroll@maryland.gov