What is referring physician?
The physician who refers a patient for a service or supply that they cannot directly provide. Often a physician will refer a patient when it becomes necessary for them to see a specialist or to have a specific service or test performed. In many Medicare Managed Care Plans it is necessary for a beneficiary to obtain a written referral from their plan-approved caregiver in order to have these additional services paid by Medicare.
Instructions for Ordering/Referring Providers
There are three basic requirements you must meet in order to be considered eligible to order/refer services.
They are:
1.The physician or NPP must enroll in Medicare, either in an approved or an opt-out status.
2.The ordering/referring National Provider Identifier (NPI) must be for an individual
physician or NPP (not an organizational NPI).
3.The physician or NPP must be of a specialty type that is eligible to order and refer. If you are not sure you are enrolled in Medicare, check the Ordering Referring Report located on the CMS website (http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html).
** If you ARE listed on the report, you have a current enrollment record in Medicare that contains your NPI
** If you ARE NOT listed on the report, you will need to verify your NPI and Medicare enrollment record
Ordering, Prescribing, and Referring Providers
Frequently Asked Questions
Q: What provider types are impacted?
A: Inpatient Outpatient (except clinic visits-rev codes 510-519, ER visits-rev codes 450-459, and observation-rev codes 760-769) Freestanding Psychiatric Hospitals Pharmacy Skilled Home Health Independent Radiology Independent Laboratory Durable Medical Equipment (DME) Chiropractor Dialysis Ambulatory Surgical Centers and Hospice.
Q: Who is eligible to order/refer?
A: Only Medicaid– enrolled individuals of the following types can order/refer:
Certified Nurse-Midwives
Clinical Nurse Specialists
Clinical Psychologists
Clinical Social Workers
Interns, Residents, and Fellows*
Nurse practitioners Optometrists (may order and refer only laboratory and X ray services) Physician’s Assistants And Physicians (Doctors of Medicine or Osteopathy, Doctors of Dental Medicine, Doctors ofDental Surgery, Doctors of Podiatric Medicine, Doctors of Optometry)
*Interns and non-licensed residents must use the NPI of the teaching, admitting, or supervising physician.
Q: How will I know if an OPR provider is enrolled with RI Medicaid?
A: It is ultimately the responsibility of the RI Medicaid provider rendering the service to obtain the OPR provider’s NPI and taxonomy code, and to confirm participation with RI Medicaid. RI Medicaid maintains a provider search function on the website, although all providers may not be listed.
Q: How will I know the NPI of the physician or health care professional who wrote the prescription or order?
A: A prescribing physician or licensed health care provider should be including their NPI on the prescription or order.
Q: I am a member of a group. As an OPR provider, do I list my group NPI or my individual NPI?
A: Only individual NPIs are accepted as an OPR provider on a claim.
Q: What information is required on a Prior Authorization Request?
A: The OPR provider’s information must be listed in the OPR fields. The Performing/Billing provider information should be listed on the Performing/Billing Provider line. If the OPR information is missing, or the OPR is not enrolled with RI Medicaid, the PA form will be returned.
Q: What will happen to a qualifying claim submitted without a OPR listed?
A: The claim will be denied by RI Medicaid with EOB message 574– Referring/Ordering Provider Required and Missing or Invalid.
Q: What is required on a crossover claim?
A: If Medicare makes a payment, RI Medicaid will process without the OPR information. If Medicare does not make a payment, the claim is no longer a crossover claim, and WILL require the OPR Information.
Q: Where is the OPR information entered on a paper claim form**
A: UB-04 – Box 79 – Other– Referring Provider NPI, Box 81CC (Row d) “B3” Qualifier followed by Referring Provider Taxonomy Code
Q: Where can I obtain the OPR taxonomy code, if I only have the NPI?
A: This information can be found on the NPPES website, by completing a provider search by NPI.
Q: Where is the OPR information entered for electronic claims**
A: For electronic submission of claims (Non-PES users), the OPR information should be entered in Loop 2310A for professional claims and Loop 2310F for institutional claims. Both the name and the NPI are required.
Q: I use the Provider Electronic Solutions (PES) software. Will I need to upgrade the software?
A: Yes. Install the 2.08 PES upgrade from the EOHHS website. Information for OPR is entered and then selected from the “Other Provider” field in the software. The following information must be entered for the OPR: NPI, Taxonomy, Provider Name, Tax ID, and Provider Address. Entering information for the OPR on the Other Provider screen will generate a list. When entering the claim information, you will be able to select the provider from the drop down list in the Referring Provider field
Q: Will claims submitted with an NPI for a non-Medicaid OPR be denied?
A: Claims submitted with complete information will be subject to a post-claims review. If it is determined that the OPR listed on the claim is not enrolled as a RI Medicaid provider, the claim may be recouped.
Q: If RI Medicaid is secondary, is the OPR provider still required?
A: Yes. The enrollment requirement applies even if Medicaid is the secondary payer.
Q: What if the OPR provider is enrolled with another state’s Medicaid program**
A: Enrollment in another state’s Medicaid program does not exempt a provider from enrolling with the RI Medicaid program.
Q: I wish to enroll as a RI Medicaid provider. Where do I go to enroll in the Medicaid program?
A: RI Medicaid moved to an electronic enrollment process on July 30.
The Provider Enrollment Portal can be accessed by visiting the Healthcare Portal and clicking Provider Enrollment. Please note the following:
1. The Provider Enrollment Portal is now available.
2. Paper applications are no longer accepted, except for attending providers being added to an existing group.
Q: What is the effective date of this change?
A: Claims submitted with a date of service of October 1, 2015 or after must include the OPR information.
