Non-Billing Ordering Providers Must Be Enrolled In Medicaid

New York State Medicaid Program posted new applications on April 1, 2013 for non-billing providers that order, prescribe, and/or refer beneficiaries with fee-for-service Medicaid coverage. New Jersey Medicaid required all such providers to be enrolled an “non-billing” providers by Jan. 1, 2013.

To comply with the new requirements under the Affordable Care Act (ACA), the Center for Medicare & Medicaid Services (CMS) issued regulations requiring State Medicaid agencies to mandate all ordering or referring physicians or other professionals providing services under the Medicaid program to be enrolled as participating providers.

Non-billing providers are healthcare professionals who refer, order, operate, prescribe, or attend to the medical needs of a Medicaid beneficiary but do not bill the program. Their enrollment in State Medicaid programs is now mandated in order for a covered service fee, like charges for pharmacy services, to be paid to the provider of those services.

The ACA also requires all providers, both billing and non-billing, who participate in State Medicaid programs to be identified by their National Provider Identifier (NPI).

While New York Medicaid has yet to issue a deadline for non-billing provider enrollment, New Jersey Medicaid announced through a newsletter to all providers that, following a 15 day grace period, payments will be denied.

When a FFS provider is requesting a NJCC/NJFC/Medicaid payment and the referring, ordering, operating, prescribing or attending practitioner reported on the claim is not enrolled as a NJFC/Medicaid provider, the FFS provider who rendered the prescribed, ordered or referred service will not be paid by the NJCC/NJFC/Medicaid program. The NPI of the ‘non-billing’ provider must be appropriately reported by the provider rendering a service on a healthcare claim, including pharmacy claims.

The Medicaid programs of both states have developed abbreviated application forms for non-billing provider enrollment.

If you have a question about Medicaid or Medicare Programs, provider enrollment, revalidation or participation or have other legal questions, please contact us here.