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Ordering, Referring and Prescribing (ORP) Frequently Asked Questions

Background and Requirements

  1. Why is Medi-Cal requiring Ordering, Referring, and Prescribing (ORP) Providers to enroll as Medi-Cal providers?

    This is being done to comply with program integrity provisions of the Affordable Care Act (ACA), section 6401 found in the Code of Federal Regulations: 42 CFR § 455.410(b) which states the State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan enroll as participating providers.

    The California statute states: Welfare and Institutions Code (W&I Code), Sections 14043.1(b) and (o) require the enrollment of ORP providers as participating providers in the Medi-Cal program. W&I Code, Section 14043.15(b)(3) provides that the National Provider Identifier (NPI) of the ORP provider must be listed on all claims for reimbursement.

  2. What are the requirements for ORP?

    There are three basic requirements for ORP services for Medi-Cal members:

    • 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.
    • The provider's NPI must be a Type 1 NPI for an individual physician or non-physician practitioner (not an organizational NPI).
    • 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. An individual's NPI is a Type 1. An organization's NPI is a 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?

    No. Providers already enrolled as active, Type 1 Medi-Cal billing or rendering providers do not need to enroll again as an ORP provider.

  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, prescribe or refer to recipients. 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 member must be enrolled in Medi-Cal or Medicare with a 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.
    Note: Providers must have their own individual NPI to enroll as an ORP provider. Providers may not use their Type 2 (organization) NPI.

    Step 2: Complete an application using the Provider Application and Validation for Enrollment (PAVE)

    After obtaining an NPI, log into PAVE and complete the ORP Provider application.
  8. If I cannot complete the Provider Application with PAVE can I still use the paper form?

    Yes, the Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement for Physician and Non-Physician Practitioners (Form 6219) is still available on the Medi-Cal website.

    Processing and approval of paper applications may take longer. Alternatively, you can contact the Provider Enrollment Division team by using one of the following methods:

    Website Provider Enrollment Division
    Telephone PAVE Call Center 1-866-252-1949
    Mail Department of Health Care Services
    Provider Enrolment Division
    MS 4704
    P.O. Box 997412
    Sacramento, CA  95899-7412
  9. If I'm enrolled in Medicare as an ORP do I need to enroll in Medi-Cal?

    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.

  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.

    In the coming months, Medi-Cal will launch an open web application that will allow billing providers to validate the enrollment status of an ORP NPI and confirm whether the ORP NPI is known to Medi-Cal.

  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 Medi-Cal Enrollment Portal.

  15. When will Medi-Cal begin enforcement of the ORP requirements on claims?

    At this time Medi-Cal has not specified a date for enforcement of the ORP requirements. Once Medi-Cal has determined the details for ORP enforcement they will be posted to the Medi-Cal website. Please continue to monitor this website for additional details.

ORP Enrollment

  1. If I do not want to be an enrolled Medi-Cal provider or be reimbursed for my services, do I still need to enroll in Medi-Cal as an ORP provider?

    Yes. If you order, refer or prescribe items or services to Medi-Cal recipients, you must enroll as an ORP provider. Failure to enroll can result in the order, referral, or prescription being denied and the patient not able to receive the services.

  2. I am already enrolled in Medi-Cal or Medicare with my Type 2 (organization) NPI. Do I need to enroll again as a Medi-Cal ORP provider so I can order, refer or prescribe?

    Yes. If you are currently enrolled with your Type 2 NPI, you must enroll in Medicare or Medi-Cal with your Type 1 NPI for the sole purpose of ordering, referring or prescribing items or services to Medi-Cal recipients.

  3. How do we report a “resident physician”?

    Interns and non-licensed residents do not qualify to enroll as Medi-Cal ORP providers. They must use the NPI of the teaching, admitting or supervising physician on the reimbursement claim form.

  4. If a clinician has a National Provider Identifier (NPI) or a license, is s/he enrolled in Medi-Cal?

    Possessing an NPI or a license does not mean a provider is enrolled in the Medi-Cal program. To be an enrolled Medi-Cal provider, you must submit an enrollment form to the Department of Health Care Services.

  5. If I enroll as a Medi-Cal ORP provider, will I be able to bill Medi-Cal directly for services that I provide?

    No. Medi-Cal ORP providers enroll solely for the purpose of ordering, referring or prescribing items or services for Medi-Cal recipients. To bill Medi-Cal directly for services provided, you must submit a full application package as required by the Medi-Cal program and enroll as a Medi-Cal provider by accessing the Medi-Cal Enrollment Portal.

  6. If my ORP enrollment request is approved, will I be notified?

    Yes. Approved applicants will receive notification of acceptance from Medi-Cal.

  7. If I am approved as an ORP provider and need to make changes to my enrollment file, what do I do?

    Providers should visit the PAVE Portal for information on how to update their enrollment file.

  8. Whom should I contact if I have questions regarding enrollment in the Medi-Cal program?

    Providers can contact the Provider Enrollment Division team by one of the following methods:

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

Program and Service Specific Information

  1. Do the ordering/referring/prescribing requirements apply to prescriptions?

    Yes, the prescriber listed on the fee-for-service claim must be known to Medi-Cal. This includes prescribers ordering prescriptions for fee-for-service Medi-Cal recipients.

  2. As a Mental Health provider servicing Medi-Cal members through County mental health plans, do I need to be enrolled as an ORP?

    Mental Health providers that order, refer, or prescribe covered Medi-Cal services are required to enroll in Medi-Cal as an ORP with their Type 1 NPI in order for the billing provider to be reimbursed.

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