Background and Requirements

1. Why are Ordering, Referring and Prescribing (ORP) providers required to enroll as Medi-Cal providers?

   Traditionally, most providers have enrolled in the Medi-Cal program to furnish covered services to Medi-Cal beneficiaries. However, with the implementation of the Affordable Care Act (ACA), some providers are required to enroll in the Medi-Cal program for the sole purpose of ORP services for Medi-Cal beneficiaries. These providers do not send direct claims to Medi-Cal for the services they furnish.

   State Medicaid agencies must require 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 pursuant to by 42 Code of Federal Regulations (CFR), Section 455.410(b). Additionally, 42 CFR, Section 455.410(c), provides that the State Medicaid agency may rely on the results of the provider screening performed by any of the following: (1) Medicare contractors, (2) Medicaid agencies or (3) Children’s Health Insurance Programs of the States. Moreover, 42 CFR, Section 455.440 provides that the State Medicaid agency must require all claims for the payment of items and services that were ordered, referred, or prescribed to contain the National Provider Identifier (NPI) of the physician or other professional who ordered, referred or prescribed such items or services.

   Effective January 1, 2013, Welfare & Institutions (W & I) Code, Sections 14043.1(b) & (o) require the enrollment of ORP providers as participating providers in the Medi-Cal program. Additionally, W&I Code, Section 14043.15(b)(3) provides that the NPI of the ORP provider must be listed on the claims for reimbursement.

2. What are the requirements for ORP-only providers?

   The three basic requirements for ORP for Medi-Cal beneficiaries are:

   1. Either the physician or the non-physician practitioner who wrote the order, referral or prescription must enroll either as a Medi-Cal billing provider, rendering provider or as an ORP-only (non-billing) provider. Their NPI must be included on submitted claims.
   2. The provider's NPI must be a type-1 NPI for an individual physician or non-physician practitioner (not an organizational type-2 NPI).
   3. The physician or non-physician practitioner must be of a specialty type that is eligible to order, refer or prescribe.
3. What are the types of NPIs? How can I verify which type of NPI I have?

   There are two types of NPIs: individual (type-1) and organizational (type-2).

   Note: Only the type-1 NPI is allowed for ORP purposes. You may verify your NPI at the NPI Registry website.
4. I am currently enrolled as an active type-1 provider with Medi-Cal. Do I need to enroll as an ORP provider?

   Unless otherwise provided, if the provider is already enrolled in Medicare or Medi-Cal as an individual with their type-1 NPI, they are not required to enroll in Medi-Cal for the sole purpose of ordering, referring or prescribing.

5. Why should I enroll as an ORP Provider?

   Enrollment as an ORP provider will allow billing providers to receive reimbursement for covered services and supplies that providers order, refer or prescribe. If providers do not enroll before the end of the “grace period,” these same billing providers will NOT receive reimbursement and may choose to not accept and fill the order, referral and/or prescription.

6. Is there a cost to enroll as an ORP provider?

   There is no cost to enroll as an ORP provider.

7. How do I enroll as an ORP provider?

   Step 1: Get a type-1 NPI

   Any provider who orders, refers or prescribes goods or services to a Medi-Cal beneficiary must be enrolled in Medi-Cal or Medicare with their type-1 (individual) NPI. To apply for a type-1 NPI, visit the National Provider Identifier page of the National Plan & Provider Enumeration System website. Follow the instructions to get an NPI.

   Please note that providers must apply with their own individual NPI to enroll as an ORP provider. Providers may not use their type-2 (organization) NPI.

   Step 2: After obtaining an NPI, complete an ORP application using the Provider Application and Validation for Enrollment (PAVE).

8. If I cannot complete the ORP provider application in PAVE, can I still use the paper form?

   No. Pursuant to the regulatory provider bulletin entitled, “Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement for Physician and Non-Physician Practitioners (Form 6219).” ORP providers are required to submit their application for Medi-Cal enrollment via PAVE, as paper applications are no longer accepted. Providers can contact the Provider Enrollment Division (PED) by using one of the following methods:

   Website	Provider Enrollment Division
   Telephone	1-866-252-1949 (PAVE Call Center)
   Mail	Department of Health Care Services Provider Enrolment Division MS 4704 P.O. Box 997412 Sacramento, CA  95899-7412

9. Do I need to enroll in Medi-Cal if I’m enrolled in Medicare as an ORP?

   No. ORP providers enrolled in Medicare do not need to enroll in Medi-Cal. Medicare providers must be present on the Medicare Ordering and Referring list to be recognized by Medi-Cal. Any issues with the Medicare Ordering and Referring list must be addressed with Medicare.

   The Centers for Medicare and Medicaid Services’ website ORP list allows the data to be exported in a downloadable Excel format or be printed. Please follow the instructions below:

   1. Go to the Ordering and Referring page of the website.
   2. Click “View Data” near top right of screen.
   3. Click “Export” tab at top right of screen. Choose option to print data or download in Excel format.

10. What if the provider is enrolled with another state's Medicaid program? Will the provider need to enroll in states in which he or she provides service?

    Yes. Enrollment in another state's Medicaid program does not exempt an ORP provider from the requirement to enroll in Medi-Cal. The requirement for ORP providers to enroll in Medicaid programs is found in 42 CFR 455.410 and Section 1866(j) of the Social Security Act. Medi-Cal cannot accept a provider's enrollment with another state's Medicaid.

11. How does the Medi-Cal provider who is billing the service know the NPI of the ORP providers? Once the provider knows the NPI of the ORP provider, how can they tell if the ORP provider is enrolled in the Medi-Cal program?

    It is the responsibility of the Medi-Cal billing provider to obtain the NPI of the ORP provider and to confirm that the ORP provider is known to Medi-Cal and in good standing. Each provider must develop its own internal processes to ensure the enrollment requirement is met.

12. Do claims submitted to Medi-Cal Managed Care Organizations have to follow the ORP requirement?

    Medi-Cal Managed Care Organizations are not currently required to follow the ORP requirement.

13. If the provider NPI shown on the claim is not a known provider to Medi-Cal, when will claim denials begin?

    To allow time for complete enrollment of ORP providers, there will be a phase-in period (grace period) before any claims are denied. During this phase-in period, billing providers are receiving a warning message on their Remittance Advice Details (RAD) code 0558 when a claim fails the ORP requirements.

14. If I currently order, refer, or prescribe services to Medi-Cal recipients and I am not enrolled in the Medi-Cal program, but would like to enroll as a billing provider, do I have to enroll as an ORP-only Medi-Cal provider first?

    No. Providers who currently order, refer or prescribe items or services for Medi-Cal recipients may enroll as a billing provider by accessing the PAVE enrollment portal.