Implementation of Ordering/Referring Professional Enrollment Requirement

Carl J. Pucci in Finance & Reimbursement

 

As previously report in our member mailing of December 9, 2013, here is a reminder that the new claims edits are effective January 1, 2014.

As required by the Affordable Care Act, New York Medicaid has initiated claims editing requiring Medicaid fee for service enrollment for ordering/prescribing/referring/attending (OPRA) physicians and other healthcare professionals. Effective for dates of service January 1, 2014 and forward, if the OPRA professional is not enrolled, eMedNY will PEND affected claims for up to four payment cycles. Rather than deny the claim initially, the pending of these claims will provide an opportunity for OPRA enrollment applications to be processed, allowing these claims from billing providers to be paid. 

Billing providers are urged to check the 835 Supplemental file and avoid resubmitting PENDED claims. The 835 Supplemental file is transmitted with the 835 Remit Advice transaction and provides more detail on PENDED claims including up to two edit numbers and their description in positions 293 to 526 of the record layout. Claims PENDING these edits will recycle for up to 4 payment cycles and the number of times recycled is located in position 209 of the record layout. The edits and messages reported on the 835 Supplemental file are as follows:

For referring provider not enrolled:
02216 - REFERRING MMIS PROVIDER ID CAN NOT BE DERIVED

For ordering provider not enrolled:

02219 - ORDERING MMIS PROVIDER ID CAN NOT BE DERIVED

When the OPRA professional becomes enrolled, the PENDED claim will be released for processing and adjudication. If the OPRA professional is not enrolled after four weekly payment cycles, the claim will be released for processing and adjudication and then DENIED with the HIPAA Claim Adjustment Reason Code (CARC) reported on the 835 Transaction as follows:

For referring provider not enrolled:
CARC 208 - National Provider Identifier - Not matched

For ordering provider not enrolled:

CARC 208 - National Provider Identifier - Not matched

Providers may resubmit DENIED claims for reimbursement when the OPRA professional becomes enrolled, in accordance with timely billing rules. OPRA professionals who submit an application between January 1, 2014 and March 31, 2014 will be given an enrollment effective date of January 1, 2014.

For more updated FAQs on OPRA requirements, background, enrollment and claims editing, please visit the provider enrollment website.

  NYSHFA CONTACT: Carl J. Pucci
Director, Finance & Reimbursement
518-462-4800 x36