Current state and federal regulations (13 CSR 65-2 and 42 CFR § 455.410) require Ordering, Prescribing, or Referring (OPR) physicians or other professionals providing services under the state plan or under a waiver of the plan to be enrolled as participating providers with the state Medicaid agency. Federal regulation 42 CFR § 455.440 requires all Medicaid claims for payment of items and services that were ordered, prescribed, or referred to contain the National Provider Identifier (NPI) of the physician or other professional who ordered, prescribed, or referred such items or services.
Drug claims with a date of service on or after October 14, 2018, will deny unless the prescriber is actively enrolled with MO HealthNet.
All outpatient or medical claims billed using the National Drug Codes (NDC) with the appropriate HCPCS or CPT procedure code for the medication administered must also contain an actively enrolled MO HealthNet prescriber. This includes but is not limited to C-codes, G-codes, J-codes, Q-codes, S-codes and non-VFC vaccination CPT codes. For medications billed on outpatient claims the attending provider is treated as the prescriber and for medical claims the rendering provider is used.
In addition, effective October 14, 2018, MO HealthNet will no longer accept a Drug Enforcement Administration (DEA) number in the “Prescribing Provider ID” field on drug claims. Providers must submit the actively enrolled prescribing provider’s NPI in the “Prescribing Provider ID” field. Claims submitted with a date of service on or after the effective date with a DEA number in the “Prescribing Provider ID” field will deny.
The Missouri Medicaid Audit and Compliance Unit (MMAC) provides an OPR Application that can be downloaded (link) or utilized as a fillable PDF form (link). MMAC’s provider enrollment personnel will expedite all OPR applications received. Please fax completed applications to (573) 634-3105.
Authorization for emergency medications only may be obtained by contacting Pharmacy and Clinical Services at (573) 751-6963. Prescribers should immediately submit an OPR application to MMAC or a subsequent override authorization may be denied.
The “Medicaid and CHIP Managed Care Final Rule” and 42 CFR 438.602(b)(1), require states to screen and enroll, and periodically revalidate, all network providers of Managed Care Organizations (MCOs); including Ordering, Prescribing, and Referring (OPR) providers. This requirement was effective January 1, 2018. Missouri Medicaid Audit & Compliance (MMAC) enrolls all health care providers for the Missouri Medicaid program operated by MO HealthNet.
The MCOs contracted with MO HealthNet have been notified that their network providers need to be enrolled with MMAC, or have submitted an enrollment application to MMAC, by the close of business on October 31, 2018. The MCOs have been directed to remove any of their network providers who have not submitted an enrollment application to MMAC by that date.
Providers enrolled with any of the three MCOs contracted with MO HealthNet, but who are not yet enrolled with MMAC, should do so before the deadline. MMAC has streamlined MCO network provider application forms for individual providers (Individual Application) or organizational providers (Organizational Application). Providers completing the MCO network provider enrollment application will not submit claims to MO HealthNet, nor will they be required to provide any services to Medicaid Fee for Service participants.
Providers who are enrolled with MCOs under more than one National Provider Identifier (NPI) will need to make sure each of those NPI numbers are enrolled with MMAC.
Any questions regarding enrolling with MMAC as a MCO Network Provider should be submitted to MMAC.ProviderEnrollment@dss.mo.gov
