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.