News  Ordering, Referring, and Prescribing Requirements

TO:              All Providers Participating in MassHealth

FROM:     Mike Levine, Assistant Secretary for MassHealth [signature of Mike Levine]

RE:           Start Dates for Enforcing Ordering, Referring, and Prescribing Requirements

Ordering, Referring, and Prescribing Requirements

Please refer to All Provider Bulletin (APB) 286 for information regarding the ordering, referring, and prescribing (ORP) requirements under Section 6401(b) of the Affordable Care Act. APB 286 included the start dates for denials of claims that do not meet ORP requirements. Because of the COVID-19 pandemic, claim denials were paused in March 2020. 

For services that require ORP and have dates of service on or after July 1, 2023, claims will be denied if they do not meet the following ORP requirements:

• The National Provider Identifier (NPI) of the ORP provider must be included on the claim.
• The ORP provider must be an authorized ORP provider type (see list on page 2 of APB 286).

All information in APB 286 remains in effect, except the start dates for denials; information related to Health Safety Net (HSN) medical claims; and the list of services that are subject to the ORP requirements, which has been revised to include continuous skilled nursing (CSN) services.

HSN pharmacy claims processed through the Pharmacy Online Processing System (POPS) will be subject to ORP claim edits, in accordance with 101 CMR 613.03(2)(b)1 (“The Health Safety Net pays only for prescribed drugs according to the coverage rules, including 130 CMR 406.411: Prescription Requirements . . ., established by MassHealth and processed through POPS”). HSN medical claims processed through the Medicaid Management Information System and HSN payment systems will not be subject to ORP claim edits.

Affected services are listed on page 2 of APB 286. CSN services have been added to the list of services subject to the ORP requirements. Claims for CSN services must include the NPI of the ORP provider in the Ordering Provider field.

Please note that primary care clinician (PCC) referrals, and referrals by primary care providers participating in primary care accountable care organizations (participating PCPs), are currently not required, so there is no current requirement to include an ORP NPI on claims that would otherwise require a PCC or participating PCP referral. MassHealth will notify providers before reinstating PCC and participating PCP referral requirements.

Providers should continue to review their ORP-related informational messages (see pages 4–7 of APB 286) to avoid receiving denials because of these requirements after July 1, 2023.

Claims for dates of service on or after September 1, 2023, will be denied if they do not meet the requirement that the ORP provider be enrolled with MassHealth. Please note that informational messages related to this requirement will continue to be run between July 1, 2023, and August 31, 2023.

MassHealth Website

This bulletin is available on the MassHealth Provider Bulletins web page and on the ORP web page.

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Questions

Long-Term Services and Supports

• Phone: (844) 368-5184 (toll free)
• Email: support@masshealthltss.com
• Portal: MassHealthLTSS.com
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• Fax: (888) 832-3006

All Other Provider Types

• Phone: (800) 841-2900; TDD/TTY: 711
• Email: providersupport@mahealth.net
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