Section 6401(b) of the Affordable Care Act (ACA) includes requirements related to Ordering, Referring, and Prescribing (ORP) providers. If MassHealth requires a service to be ordered, referred, or prescribed, then ACA Section 6401(b) requires that
1. the billing provider include the ORP provider’s individual National Provider Identifier (NPI) on the claim.
2. the ORP provider be enrolled with MassHealth as a fully participating provider or as a nonbilling provider.
Note that there are other circumstances in which a nonbilling provider’s NPI may also be required on claims in order to comply with HIPAA version 5010 billing requirements.
To fulfill these requirements, MassHealth began enrolling qualified ORP nonbilling providers in June 2015.
When the ACA ORP requirements are fully implemented, MassHealth will deny claims for certain health care services requiring an order, referral, or prescription from a physician or other health care professional unless the ordering, prescribing, or referring provider’s individual NPI is included on the claim and that provider is actively enrolled with MassHealth, at least as a nonbilling provider. See below for more information on the affected claims.
MassHealth Services that Require an Order, Referral, or Prescription
The following services and supplies require an order, referral, or prescription from a provider in order for the billing provider to receive MassHealth payment.
- Any service that requires a PCC referral (see 130 CMR 450.118(J))
- Adult Day Health
- Adult Foster Care
- Group Adult Foster Care
- Home Health
- Independent Living
- Independent Nurse
- Labs and Diagnostic Tests
- Oxygen/Respiratory Equipment
- Personal Care
- Psychological Testing
- Therapy (PT, OT, ST)
- Transitional Living
Provider Types Authorized to Order, Refer, or Prescribe
The following types of providers are the only provider types that may be listed on a claim as the ORP provider and are referred to as authorized ORP providers. Interns, residents, and other trainees in the provider types listed below who are authorized to order, refer, or prescribe services are also considered ORP providers
- Certified Nurse Midwife
- Certified Registered Nurse Anesthetist
- Clinical Nurse Specialist
- Licensed Independent Clinical Social Worker
- Nurse Practitioner
- Pharmacist (if authorized to prescribe)
- Physician Assistant
- Psychiatric Clinical Nurse Specialist
Claims for the services listed above that are ordered, referred, or prescribed by a clinician who is not a provider type listed above must include the NPI of the clinician’s supervising physician (or other authorized ORP provider) on the claim. In that situation, the authorized ORP provider must also be enrolled in MassHealth as a fully participating provider or as a nonbilling provider in order for the billing provider’s claim to be payable. Note that pharmacy claims must include the individual NPI of the actual prescribing provider.
Massachusetts state law requires that the types of providers listed above apply for enrollment in MassHealth at least as a nonbilling provider in order to obtain and maintain state licensure. This licensure requirement will go into effect once MassHealth implementing regulations are promulgated.
Providers who wish to enroll as nonbilling providers should download the materials linked below and send their completed and signed Nonbilling Provider Application and Nonbilling Provider Contract by mail to the MassHealth Customer Service Center (CSC) at:
MassHealth Customer Service Center
Attn: Provider Enrollment
PO Box 9162
Canton, MA 02021
Dentists should submit their materials to:
MassHealth Dental Program
Attn: Provider Enrollment and Credentialing
P.O. Box 2906
Milwaukee, WI 53201-2906
Pharmacists who are eligible to prescribe should fill out a Nonbilling Provider Application designed just for them. Eligible pharmacists should call the MassHealth Customer Service Center at 1-800-841-2900 to request the Nonbilling Pharmacist Application.
Before you submit your enrollment package, please refer to the MassHealth Administrative and Billing regulations (130 CMR 450.000). All portions of these regulations that are not related to billing and payment apply to nonbilling providers. For providers eligible to be fully participating providers, please also refer to the corresponding MassHealth Provider Regulations.
MassHealth will notify you about its decision regarding your application. You are not a fully participating or nonbilling provider until MassHealth notifies you that your application has been approved.
If you have any questions about the enrollment process, or if you wish to request the materials to enroll with MassHealth as a fully participating provider, please call the MassHealth Customer Service Center (CSC) at 1-800-841-2900.
For more information about the claims impacted by the Ordering and Referring requirements see the All Provider Bulletin 259 .
Wednesday, September 14th, 2016 from 1:00 p.m–2:00 p.m
Wednesday, September 28th, 2016 from 1:00 p.m–2:00 p.m
Wednesday, October 12th, 2016 from 1:00 p.m–2:00 p.m
Wednesday, October 26th, 2016 from 1:00 p.m–2:00 p.m
Wednesday, November 16th, 2016 from 1:00 p.m–2:00 p.m
Wednesday, November 30th, 2016 from 1:00 p.m–2:00 p.m
To enroll in a webinar session, please register at the MassHealth Learning Management System (LMS) via www.masshealthtraining.com and create your profile. Once you are registered, select the preferred course date and time available.
Please note: if you are not currently a MassHealth provider and do not have access to a MassHealth Provider Identification Service Location number (PID/SL), please enter 00000000Z in this designated field.
For questions, please contact the MassHealth Customer Service Center at firstname.lastname@example.org or call 1-800-841-2900.