Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require all ordering, prescribing, and referring (OPR) providers to enroll in Medicaid, in order for those providing the services to receive payment. These rules apply even if the OPR providers don’t accept or bill Medicaid themselves. The rules were implemented in order to require additional screening of Medicaid providers to improve the integrity of the Medicaid program and to reduce fraud, waste and abuse. Therefore, when claims are submitted for payment, providers must ensure the ordering, prescribing, or referring provider (if there is one) is enrolled. In the future, if the “OPR” provider is not enrolled, the claims will be denied. Systems work is underway to accomplish this. Some billing providers have already received an informational Explanation of Benefits (“pay but report”) notice informing them that the claims will deny in the future if the “OPR” provider is not enrolled.
In order to address this requirement, a new enrollment status code has been created to identify and accommodate “OPR” providers. Click
Ordering, Prescribing, and Referring (OPR) Provider Application to access the new OPR application form.
Providers already enrolled with MO HealthNet as active providers do not need to enroll again as an OPR provider.
If providers choose to enroll as “OPR only”, they cannot submit claims to MO HealthNet for payment of services rendered. If providers wish to submit claims for payment, then they must enroll with MO HealthNet as billing or performing providers.
Again, providers who submit orders, prescriptions or referrals for Medicaid participants must enroll with MO HealthNet in order for the billing provider’s claim to be approved.
Any questions regarding OPR applications or to check to ensure your status is “active” should be sent to MMAC.ProviderEnrollment@dss.mo.gov
Since July 2015, Missouri Medicaid Audit and Compliance (MMAC) has been collecting application fees from certain applying or revalidating providers. More information about the application fee requirement is on our website at https://mmac.mo.gov/providers/provider-enrollment/new-providers/application-fee/ The Missouri Code of State Regulations has been updated to reflect a change in the application fee. You can view the regulation at https://s1.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c65-2.pdf
The regulation states the application fee is determined as follows: it is $553.00 for the remainder of the calendar year 2015. For calendar year 2016 and subsequent years, “The amount of the application fee shall be the amount for the preceding year adjusted by the percentage change in the consumer-price index for all urban consumers for the twelve- (12-) month period ending with June of the previous year as published by the Bureau of Labor Statistics of the United States Department of Labor. If the adjustment sets the fee at an uneven dollar amount, MMAC will round the fee to the nearest whole dollar amount; and the application fee will be effective from January 1 to December 31 of a calendar year.
MMAC will update our website and utilize gov.delivery messaging to notify providers of the rate for calendar year 2016.
