NY Medicaid: OPRA Provider Requirements and Impact on Pharmacies

The NYS Medicaid recently informed referring and servicing providers that, effective for services provided on and after October 1, 2013*, claims will be denied if they include the NPI of non-enrolled ordering, prescribing, referring or attending provider (OPRA). Below we discuss some of the new requirements.

As we previously discussed, the Affordable Care Act (ACA) requires 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, even if those professionals do not bill fee-for-service (FFS) Medicaid. This enrollment requirement does not apply to services paid through Medicaid managed care plan. If certain services are carved out of the plan and are paid on a FFS basis, however, the enrollment requirement applies.

The new requirement also applies to out-of-state ordering/referring providers who need to be enrolled in NYS Medicaid for services to be paid by FFS Medicaid.

Starting in October 2013*, prescriptions written by non-enrolled providers will be denied at the point-of-service. According to Medicaid, pharmacists will receive a reject code of “56” (non-matched prescriber ID) in NCPDP field number 51 1-FB and the pharmacists will not be able to override the rejected transaction if the prescribing provider is not enrolled. Medicaid recommends that once the transaction is rejected because the prescribing provider is not enrolled in Medicaid, the pharmacist either contact the prescribing provider or return the prescription to the beneficiary with the instructions to contact the prescribing provider.

Pharmacists and other servicing providers can verify the enrollment status of a prescribing/referring provider by using the OPRA Provider Search at emedny.org.

Earlier in the year, NYS implemented a streamlined enrollment process for non-billing OPRA providers. Most enrollments are processed within 30 days of receipt of a completed application. Providers interested in retroactive enrollment may contact the Bureau of Provider Enrollment after receiving their enrollment approval letter to request such retroactive enrollment.

Chiropractors,** Clinical Social workers, podiatrists and physical therapists** should note that NYS Medicaid requires prior enrollment with Medicare before enrolling with NYS Medicaid will be permitted.

*UPDATE: NYS Medicaid has advised providers that it is delaying the October 1, 2013 implementation of new claims editing requiring Medicaid enrollment for OPRA physicians and healthcare professionals until January 1, 2014.

**UPDATE: Participation in the Medicare Program is no longer required for Chiropractors and Physical Therapists enrolling in New York Medicaid as ordering/prescribing/referring/attending (OPRA) providers.

If you have a question about Medicaid or Medicare Program participation or require assistance with provider enrollment or revalidation, please contact our office.