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Updated ACA Billing and Enrollment Requirements for ORP Providers

March 8, 2017

When billing goods or services, providers are now required to list the National Provider Identifier (NPI) of the provider who ordered, referred or prescribed goods or services. This requirement is based on Patient Protection and Affordable Care Act (ACA).

Federal Medicaid Regulations (ACA)

  • 42 CFR §455.410(b) requires all ordering or referring physicians or other professionals providing services, under the State plan or under a waiver of the plan to be enrolled as participating providers.

  • 42 CFR §455.440 requires all claims for items and services ordered or referred to contain the National Provider Identifier (NPI) of the ordering or referring provider.

California Statute

Welfare and Institutions Code (W&I Code) requires ORP providers, as defined in §14043.1(b) and (o), to enroll as participating providers in the Medi-Cal program. W&I Code §14043.15(b)(3) provides that the ORP provider's NPI must be listed on all claims for reimbursement.

Each ordering, referring or prescribing (ORP) provider must be enrolled as a participating provider in Medicare or Medi-Cal, with a Type 1 (individual) NPI, even if the provider does not send claims to Medi-Cal for the services he or she provides.

In the near future, Medi-Cal will deny claims that do not meet the above requirements.

For complete details, providers should consult the materials available on the Ordering, Referring and Prescribing (ORP) Web page on the Medi-Cal website. Providers can find more information about enrolling with Medi-Cal on the Provider Enrollment Division page of the Department of Health Care Services website.

To determine which claim form to use, providers may refer to the Navigating Medi-Cal and Specialty Health Programs chart on the Medi-Cal website.

Providers can contact the Telephone Service Center (TSC) at 1-800-541-5555 for more information. TSC is available 8 a.m. to 5 p.m., Monday through Friday, except holidays (border providers and out-of-state billers billing for in-state providers, call 1-916-636-1200).