New York State Medicaid Update - December 2013 Volume 29 - Number 13

In this issue...


Ordering/Referring Enrollment and Claims Editing Implementation in Fee-For-Service (FFS) Medicaid

This Special Edition Medicaid Update provides a compilation of information, resources and links offered since 2011 to ordering, prescribing, referring, and attending (OPRA) healthcare professionals, practice managers, facility administrators, servicing/billing providers and members.

The enrollment requirement applies to all services, including prescription drugs, provided under the Medicaid state plan or under a waiver of the state plan (the FFS Medicaid program). It does not apply to services paid through a Medicaid managed care plan.

Effective January 1, 2014, FFS Medicaid will implement new FFS claims editing requiring Medicaid FFS enrollment for ordering/prescribing/referring/attending (OPRA) physicians and other healthcare professionals. If the ordering professional is not enrolled, under federal law Medicaid must deny the claim for the ordered service.

Ordering professionals who have not yet submitted enrollment applications must do so immediately to avoid future interruption of the services they order for their patients.


Pharmacy Customer Posting

Effective JANUARY 1, 2014,
Your doctor must be signed up with Medicaid!

If you use your Benefit Card* to fill your prescriptions,
your pharmacist will check to make sure your doctor is
signed up with Medicaid.

*This means you are in "fee-for-service" Medicaid. If you use your Medicaid managed care plan card to fill prescriptions, this change does not affect you.


Practitioner Notice for Medical Groups, Hospitals, Clinics, etc.


Starting JANUARY 1, 2014, you must be Medicaid-enrolled for Medicaid to reimburse other providers for prescription drugs and the other services you order for your Medicaid patients. This federal statutory requirement affects your patients who are in fee-for-service Medicaid only and does not apply to services paid through a Medicaid managed care plan.

Avoid interruptions of care:

Frequently Asked Questions and Links

A. Background and Requirements

1) Why do non-billing physicians and healthcare professionals need to enroll in the NYS Medicaid program?

The Affordable Care Act (ACA) and subsequent federal regulations (42CFR 455.410) include provisions requiring additional screening of Medicaid providers to improve the integrity of the Medicaid program and to reduce fraud, waste and abuse. Please see the December 23, 2011, CMS CMCS Informational bulletin for further details:

2) What are the benefits of enrolling in the NYS Medicaid program?

Besides ensuring that your patients will continue to receive appropriate and timely services, there are several programs offering financial incentives to Medicaid enrolled physicians and other professionals. For example, Medicaid enrollment is a prerequisite for participation in the NYS Medicaid Electronic Health Records (EHR) Incentive Program, which disburses federal incentive dollars for eligible professionals who adopt and use EHR technology: Medicaid enrollment also facilitates efficient identification, qualification and payment for physicians attesting for the Medicaid Primary Care Rate Increase: Many other programs and employers require or encourage Medicaid enrollment as well.

3) What professions must enroll in fee-for-service Medicaid?

Physicians and other healthcare professionals ordering/referring services provided under the state plan or under a waiver of the state plan must enroll in Medicaid. The order or referral must be within the professional's scope of practice and comply with program rules regarding ordering/referrals.

4) Does this requirement apply to managed care providers?

The ordering/referring enrollment requirement does not apply to services paid through a Medicaid managed care plan. However, if the service is carved out of the plan benefit package and is paid fee-for-service, the requirement applies. For example, all family planning services are carved out of Fidelis Care and are paid by Medicaid fee-for- service.

5) In a clinic there are registered nurses and other health professionals that support the physician; do these professionals need to enroll as ordering/referring providers?

In medical clinics, registered nurses and health professional support staff are not typically ordering or referring services, so they would likely not need to enroll as ordering/referring professionals. Note that if these staff are reported in the Attending provider field on the clinic claim, the medical practitioner who is responsible for ordering/referring should be reported in the Referring provider field.

6) Does a servicing/rendering professional need to enroll as ordering/referring?

If a servicing/rendering professional is also ordering/referring within his/her scope of practice and the program, the professional will need to enroll. If a servicing professional is not ordering or referring services, he/she does not need to enroll.

7) Must the ordering practitioner be enrolled in the NYS Medicaid Program at the time s/he writes the order?

It is the billing provider's responsibility to ensure that all required documentation is in place prior to submission of a Medicaid claim, including checking the status of the ordering provider, who must be enrolled on the date of service. The ordering provider's enrollment status may be checked by accessing the following link: or by calling Computer Sciences Corporation (CSC) at (800) 343-9000.

8) If new information is issued about the implementation of the ordering/referring requirement, how can I make sure I am aware of it?

New information will be posted at, included in Medicaid Updates and shared through the eMedNY LISTSERV(r). If you do not already subscribe to the eMedNY LISTSERV(r), you may enroll at:

9) What documentation is a Medicaid provider required to contemporaneously create and maintain regarding orders/referrals from OPRA professionals who cannot enroll in Medicaid?

As always, Medicaid providers are required to create and/or maintain contemporaneous documentation in the patient files of the identity and contact information of all ordering, referring, prescribing, attending and servicing professionals. The contact information must include the professional's full name, address, phone number order/referral date and, if available, the email address. The provider must also maintain the full name, including any aliases, and the social security number if employed or under contract with the provider, in its own files. This documentation must be provided upon request by the State.

There are more than 92,000 practitioners
enrolled in New York State Medicaid and over
11,000 have enrolled in 2013!

B. Ordering/Prescribing/Referring/Attending (OPRA) Enrollment

1) If a clinician has a National Provider Identifier (NPI) or a license, is s/he enrolled in Medicaid?

Possessing an NPI or a license does not mean you are enrolled in the Medicaid program. To be an enrolled provider, you must submit an enrollment form to the New York State Department of Health.

2) What does "enrolled in Medicaid" mean?

To be enrolled in the New York State Medicaid program, a Medicaid enrollment form must be submitted and approved by the New York State Department of Health.

3) I am already actively enrolled in Medicaid. Do I need to enroll as OPRA, too?

Individuals already actively enrolled as practitioners do not need to enroll as OPRA as well. If you are unsure of your Medicaid enrollment status, please check here:, or call CSC at (800) 343-9000.

4) How do I enroll as ordering/referring?

Visit the eMedNY website at: and click on your provider type's Provider Enrollment page for the OPRA form. Be sure to complete all required fields, answer all questions and provide all required documentation. For assistance with enrollment application questions, contact CSC at (800) 343-9000.

5) Is Medicare enrollment required prior to Medicaid enrollment?

Medicare enrollment is a requirement for Medicaid enrollment as an OPRA provider for Clinical Social Workers and Podiatrists. Medicare enrollment is not a requirement for other professionals enrolling in Medicaid as OPRA providers.

6) What is the turn-around time for the expedited OPRA enrollment process?

Most enrollments are processed within 30 days of receipt of a completed application.

7) I submitted my enrollment form and want to verify it was received. Who do I contact and what do I need when I call?

Applicants may call Computer Sciences Corporation at (800) 343-9000 to confirm their application was received. Please allow two weeks before calling to allow for mailing time, review for completeness, and entry into the enrollment system. Please have your NPI and Social Security Number (SSN) available when you call.

8) Can the Medicaid enrollment be back dated?

Completed applications received before January 1, 2014, if approved, will have an October 1, 2013 effective date. OPRA applications received from January 1, 2014 through March 31, 2014 will receive a January 1, 2014 effective date.

9) To ensure my enrollment form can be processed expeditiously, what should I be aware of when completing the form?

Please be sure to follow the directions which accompany the enrollment form. Many applicants fail to complete all required fields which results in their enrollment form being returned. ALL fields must be completed UNLESS otherwise instructed. Although rare, if your situation is such that there are no managing employees to report in Section 5 on page 4, indicate "None" in the "Name" field in the first block. When reporting managing employees, you MUST provide their home address, SSN, date of birth and their Association type (see instructions).

10) In a school/agency setting for Section 5, Managing Employees, please clarify: are supervisors and administrators of school districts, or immediate supervisors of the applying therapist considered to be Managing Employees?

Administrators, supervisors, and office managers may be considered managing employees. It is recommended that applicants refer to and read the regulatory references included on the Ordering, Prescribing, Referring and Attending Practitioner application form. If the office manager or administrator, or a supervisor of the applying therapist within the school or county exercises operational or managerial control over the day to day operations of the provider (service provision) then that individual(s) should be reported in Section 5 of the application.

11) Do the Medicaid provider numbers expire?

The Medicaid enrollment will not be automatically terminated for non-billing. However, providers will have to revalidate their enrollment periodically.

12) Do out of state ordering/referring professionals need to be enrolled in NYS Medicaid?

Yes, out of state professionals ordering/referring for services paid by fee-for-service Medicaid must enroll.

13) Are OPRA providers required to sign up for EFT and e-Remittance?

No. Since OPRA providers do not bill Medicaid for their services, they are not required to sign up for electronic fund transfer or electronic/PDF remittances.

14) I am a professional who has completed my eMedNY affiliation requirement with a facility or agency. Do I need to enroll?

You do not need to enroll if you are a servicing provider only. If you are ordering or referring services, you must enroll in Medicaid. Completing the affiliation requirement does not mean that you are enrolled in Medicaid.

15) If I enroll as an OPRA provider, will I be required to accept Medicaid patients in my practice/group?

No. Enrolling as an OPRA provider does not require you to accept new patients to your practice or group.

16) Can the enrollment form be completed by someone other than the practitioner? Can the enrollment form be submitted without the practitioner's approval?

The enrollment form can be completed by a person other than the applicant. However, the applicant must sign the enrollment form and is responsible for the accuracy of its content. An enrollment form, therefore, cannot be submitted without the applicant's approval.

17) If my OPRA enrollment request is approved, will I be notified?

Yes. Approved applicants will receive an accepatance letter from the Medicaid program.

18) As an approved provider, will my contact information be made public after I enroll?

Your name, license number and NPI will be on the Search feature on the eMedNY website so that servicing providers will know you are eligible to order/refer.

19) When searching for OPRA verification, are only OPRA enrolled practitioners shown?

The Search results include both OPRA-enrolled providers as well as enrolled practitioners whose services are billable to Medicaid. Organizations such as hospitals, clinics, nursing homes, etc., are not included in the search feature. However, individuals who are employed by institutions and have enrolled as OPRA or billing providers will be included.

20) If I am approved as an OPRA provider and need to make changes to my enrollment file, what do I do?

Providers should visit the Provider Enrollment and Maintenance pages at for information on how to update their enrollment file. For further information, please call Computer Sciences Corporation at (800)343-9000, Monday through Friday, 7:30 a.m. to 6 p.m.

21) I am a practitioner eligible for Medicaid enrollment. I am not interested in enrolling in New York Medicaid, even as an OPRA provider. What do I do?

Explain to your patients that federal law prevents Medicaid from paying for services and medications you order unless you have signed up with Medicaid. Help them find another practitioner who is enrolled in Medicaid. If you have a particular practitioner in mind, use the search tool found here to determine if the practitioner is enrolled in Medicaid:

22) Are Medicaid claims for care, services or supplies reimbursable when the OPRA professional has been excluded or has violated any condition of participation in the Medicaid program and therefore cannot enroll in Medicaid?

No, these claims are not reimbursable because the OPRA professional may not order, refer, prescribe, attend or provide care, services or supplies to Medicaid beneficiaries, even if another MMIS/NPI number, including that of an institutional provider, is reported.

C. Program & Service Specific Information

1. When will I get guidance from my program on ordering/referring?

Programs, including Pharmacy, Office for People With Developmental Disabilities (OPWDD), Office of Mental Health (OMH), Office of Alcoholism and Substance Abuse Services (OASAS), Early Intervention, Waivers and School Health have provided guidance through their communication channels. Common questions for these programs and services are included below.

Prescription Drugs

2. Do the ordering/referring requirements apply to prescriptions and pharmacy claims?

Yes, the prescriber listed on the fee-for-service drug claim must be enrolled in NYS Medicaid. This includes prescribers ordering prescriptions for fee-for-service Medicaid beneficiaries in long term care facilities.

3. As a pharmacist, what do I do if I receive a new script written by a practitioner who is not enrolled in the Medicaid Program?

Beginning January 1, 2014, Medicaid will not reimburse you for prescriptions written by practitioners not enrolled in the Medicaid program. In this Special Edition Medicaid Update you will find an informational posting to share with Medicaid fee-for-service members.

4. What should a patient do if they are told their prescriber is not enrolled in Medicaid and therefore their prescription is not covered?

Members should contact their prescriber.

5. What messaging will the Pharmacist receive, via NCPDP transaction, if the prescriber is not enrolled?

Pharmacies will receive a Reject Code of "56"- (Non matched Prescriber ID) in NCPDP field number 511-FB.

6. Can a pharmacist override a rejected transaction if the prescriber is not enrolled?


7. What should a pharmacist do once a transaction is rejected?

Pharmacists can either contact the prescriber or return the prescription to the member to contact the prescriber.

8. Since Medicaid does not enroll unlicensed medical residents, whose NPI should be used on the prescription?

Prescriptions written by unlicensed medical residents must include the NPI of their supervising/attending physician who is enrolled in Medicaid.

9. If a prescriber writes a prescription for a drug which requires prior authorization, can they obtain prior authorization if they are not enrolled in Medicaid?

No. The prescriber must be enrolled in Medicaid, on the date of the request, in order to receive prior authorization for a drug. Prior authorization cannot be issued retroactively.

School Supportive Health Service Program (SSHSP)

10. My school is a SSHSP provider. When Medicaid refers to the "attending practitioner", who does that mean?

Medicaid uses the term "attending" in the OPRA provider enrollment application in reference to attending physicians.

Medicaid uses the term "attending" in the SSHSP when referring to the clinician who has overall responsibility for the student's medical care. The servicing provider is the clinician that provides services to the student on a regular basis. In cases where the servicing provider works "under the direction of/or under the supervision of" a licensed clinician, the directing/supervising clinician is considered the "attending" clinician. For purposes of reporting NPI numbers on SSHSP Medicaid claims, the attending provider's NPI must be used where the attending provider and the servicing provider are not the same individual.

11. According to the March 2013 Medicaid Update, Physical Therapists (PTs), Occupational Therapists (OTs) and Speech-Language Pathologists (SLPs) (among others) must enroll in the state Medicaid program if they are going to order or refer services that will be reimbursed by the fee-for-service Medicaid program. Is it correct to assume that this requirement also applies to PTs, OTs, SLPs who are employed by a school district or county and provide these services to children where the county or school district bills?

The March 2013 Medicaid Update article titled "Expedited Enrollment for Ordering, Prescribing, Referring & Attending Practitioners" is specific to practitioners who are ordering services. In the SSHSP, SLPs can order services, as can physicians, physician assistants and nurse practitioners. PTs and OTs cannot order services; therefore they do not have to enroll as ordering providers for the SSHSP. However, if PTs and OTs are working for other provider types (e.g., hospital, clinic, other), they may be required to enroll.

12. Is a new order/referral needed for psychological evaluation and counseling ordered by non-enrolled Licensed Clinical Social Workers (LCSWs) and psychologists?

SSHSP billing providers must ensure that all required documentation is in place prior to the submission of a Medicaid claim. If the psychological evaluation or psychological counseling services are ordered by an enrolled ordering provider (a licensed physician, psychiatrist, physician assistant, nurse practitioner or a licensed psychologist for purposes of the SSHSP), that provider's NPI number must be included on the Medicaid 837I claim form in the referring provider field. If the psychological evaluation or psychological counseling services are referred by an individual who is not eligible to enroll as an ordering/referring provider in the SSHSP (e.g., a school official, classroom teacher, or other licensed provider such as an Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW), the Medicaid 837I (institutional) claim form must include the NPI of the billing provider in both the billing and referring provider fields.

Office of Mental Health (OMH) Programs

13. Does this OPRA enrollment requirement apply to OMH program types?

Yes, this requirement applies to all OMH program types submitting claims to Medicaid.

14. Our mental health program has never filled out the attending section of the claim. Do we need to do so now?

No. The requirements have not changed. If an attending was not required on claims prior to 1/1/14, it is not required after. However, if an attending was required an attending is still required.

15. Our mental health program has never filled out the referring section of the claim. Do we need to do so now?

Yes, if the attending clinician reported on the claim is not enrolled in Medicaid you must report the (enrolled) clinician in the referring field. As appropriate you should report the NPI of the (enrolled) physician who signed the treatment plan or the NPI of the (enrolled) individual who supervises the attending clinician. Using your agency's NPI in the referring field may be appropriate in some cases. Please contact OMH Financial Planning by email with questions.

16. Licensed Master Social Workers (LMSWs) provide services in our mental health program. We use their NPIs in the attending field on claims when billing Medicaid for the services they provide. Since Medicaid does not enroll LMSWs, can we continue to report their NPI on our claims?

Yes. The clinician performing the service continues to be entered as the attending provider on the claim. However, an enrolled referring professional must be added to the claim. As appropriate, you should report the NPI of the (enrolled) physician who signed the treatment plan or the NPI of the (enrolled) individual who supervises the LMSW. Using your agency's NPI in the referring field may be appropriate in some cases. Please contact OMH Financial Planning by email with questions.

17. Our program employs professionals who are not eligible for enrollment in the Medicaid Program. OMH has given us a generic Medicaid provider ID to report in the attending provider field on our Medicaid claims when these professionals provide the service. Can we continue to use this provider ID?

Yes, continue to report the generic provider ID in the Attending NPI field on the claim as directed. The ordering/referring provider ID must also be reported in the Referring NPI field.

Office for People with Developmental Disabilities

18. Is there any impact on use of the generic "bypass" MMIS provider ID for Rehabilitation Counseling services and Intake services provided by unlicensed staff in OPWDD Article 16 clinics?

Article 16 clinic providers should continue utilizing the generic bypass provider ID for services rendered by Rehabilitation Counselors and for Intake services rendered by qualified non-licensed staff in the Attending NPI field of the claim submission. Article 16 clinic providers will however, be required to identify and include the NPI of the staff person responsible for ordering/referring the service on each claim in the Referring provider field.

19. Our agency operates an Article 16 clinic certified by the New York State Office for People with Developmental Disabilities (OPWDD). We currently include the NPI of the rendering clinician in the attending field of the claim submission. Do we need to include information in the referring field of our claim submissions?

Yes. For most services provided in an Article 16 clinic, the ordering/prescribing/referring practitioner will be the clinic medical director or practitioner responsible for signing the clinic treatment plan per requirements at 14 NYCRR 679.3(q) and 14 NYCRR 679.4(h). In such circumstances, the NPI of the medical director or other

practitioner signing the clinic treatment plan should be inserted into the referring field of the claim. These staff must be enrolled in Medicaid as ordering/prescribing/referring practitioners. When occupational therapy, physical therapy, or speech-language pathology services are ordered, prescribed, or referred by a medical practitioner not employed or contracted by the clinic, the practitioner must be enrolled in Medicaid as an ordering/prescribing/referring practitioner.

OPWDD guidance for entries in the attending clinician field has not changed. If the clinician who rendered services has an NPI, that clinician's NPI should be included as the attending provider on the claim. This includes licensed, registered, or certified "dependent" clinicians who work under supervision, such as Physical Therapy Assistants (PTAs) and Occupational Therapy Assistants (OTAs). OTAs and PTAs are eligible for NPIs. When they deliver services in a clinic, it is the OTA's or PTA's NPI that should be sent -not their supervisor's NPI. There are four groups of clinicians not eligible to receive NPIs. They should be handled as follows:

  • Applied Behavioral Sciences Specialists (ABBS): The NPI of the supervising psychologist should be used.
  • Students-In-Training: The NPI of the supervisor should be used.
  • Rehabilitation Counselors: The license bypass code "02249136" should be used.
  • Unlicensed Treatment Coordinators (intake visits only): The license bypass code "02249136" should be used.

Please contact OPWDD's Bureau of Central Operations at (518) 402-4333 if additional information is required.

NYSDOH Home and Community Based Waiver Programs

20. As a waiver provider, we cannot obtain an NPI and the orders/referrals are from professionals who also cannot obtain NPIs. How do I comply with the ordering/referring requirement?

Whether or not providers are required to obtain NPIs depends on what type of service they provide. There are Medicaid reimbursable services that are not purely medical or clinical in nature, and therefore the provider of the service does not have an NPI. These providers are approved by NYSDOH to provide services through Home and Community Based Services (HCBS) waiver programs such as Nursing Home Transition and Diversion (NHTD), Traumatic Brain Injury (TBI) and Care at Home (CAH). These are identified and categorized as "atypical providers." When an order/referral originates from a professional who cannot obtain an NPI, the State will allow the atypical waiver provider to report its MMIS provider ID in the Attending provider field as long as the proper waiver service rate code is reported on the claim. The Referring provider field is left blank.

Early Intervention (EI)

Additional information specific to EI providers will be available soon.

D. Claims and Billing

1) When must the attending professional be enrolled (institutional claims)?

The attending (ordering, referring and/or servicing) professional must be enrolled if the Referring provider field is blank on the institutional (837I) claim. This is because the attending provider is considered the ordering/referring provider in the absence of a referring provider. If professionals are reported as the attending provider when they the servicing provider only, the enrolled ordering/referring provider's NPI is reported in the Referring provider field on the claim.

2) In programs where an order from a medical practitioner is not required, who is reported as the ordering/referring professional? Does this professional need to enroll?

According to CMS, all services require an ordering/referring provider. Where a practitioner eligible for enrollment is the professional who ordered/referred the service, that practitioner is required to enroll and would be reported in the Referring provider field on the claim. Also see Question 4.

3) What is the time frame for compliance?

Providers should be reporting ordering/referring professionals on claims now. Enforcement of the enrollment requirement in claims processing will begin on January 1, 2014 for dates of service on and after January 1, 2014.

4) What if Medicaid does not enroll the ordering/referring profession type for the service billed and this professional may order/refer according to program rules.

In some Medicaid funded programs, the order/referral may originate from a professional who Medicaid does not enroll. If the professional is authorized by the State to order or refer services but is not authorized to enroll in NY Medicaid, the State will allow the institutional provider who employs the professional to report their NPI as the ordering/referring. There are two options for billing providers:

  • In most cases, institutional providers should report their NPI in the Attending provider field. An MMIS provider ID should be reported in the Attending provider field by atypical providers and by providers directed by their program to report a generic (or "bypass") MMIS provider ID. The Referring provider field is left blank.
  • In some programs, the servicing professional may obtain an NPI but is not enrollable in Medicaid. When directed by programs, the servicing professional NPI is reported in the Attending provider field. The institutional provider NPI is then reported in the Referring provider field.
  • A Medicaid institutional provider cannot report its own NPI or MMIS in the Referring or Attending fields when the referring or attending provider has been excluded from the Medicaid program.

5) What edit message will I see on my 835 remittance statement if the ordering/referring provider is not enrolled?

02216 - Adjustment Reason Code CO 208 (NPI -NOT MATCHED),

02218 - Adjustment Reason Code CO 208 (NPI -NOT MATCHED),

02219 - Adjustment Reason Code CO 208 (NPI -NOT MATCHED),

6) I have an order, referral or prescription from a healthcare professional. How do I know if he/she is enrolled in NYS Medicaid?

Refer to the search tool available at

7) What can I do to avoid denial of my claim?

It is important that providers communicate with their ordering professionals on a regular basis to urge them to enroll in Medicaid. Providers who fail to confirm the ordering professional's Medicaid enrollment status (see web address in answer above) will be putting their Medicaid payment at risk.