Background
If MassHealth requires a service to be ordered, referred, or prescribed, then ACA Section 6401(b) requires that the
- Billing provider include an authorized ORP provider’s National Provider Identifier (NPI) on the claim, AND 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 an authorized ordering, prescribing, or referring provider’s 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
- Continuous Skilled Nursing
- DME
- Eyeglasses
- Group Adult Foster Care
- Home Health
- Independent Nurse
- Labs and Diagnostic Tests
- Medications
- Orthotics
- Oxygen/Respiratory Equipment
- Prosthetics
- Psychological Testing
- Therapy (PT, OT, ST)
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 Nurse Practitioner
- Certified Registered Nurse Anesthetist
- Clinical Nurse Specialist
- Dentist
- Licensed Independent Clinical Social Worker
- Optometrist
- Pharmacist (if authorized to prescribe)
- Physician
- Physician Assistant
- Podiatrist
- Psychiatric Clinical Nurse Specialist
- Psychologist
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.
Enrollment Instructions
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 and Credentialing
P.O. Box 278
Quincy, MA 02171-0005
Or by fax to 617-988-8974
Dentists should submit their materials to:
MassHealth Dental Program
Attn: Provider Enrollment and Credentialing
P.O. Box 2906
Milwaukee, WI 53201-2906
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 at (800) 841-2900.
Claims Denials
MassHealth and the HSN have been using informational edits to help providers prepare for the full implementation of the ORP requirement. In March 2020 claims denials were paused due to the COVID-19 pandemic.
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).
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.
For more information about the ORP requirements see All Provider Bulletin 361: Start Dates for Enforcing Ordering, Referring, and Prescribing Requirements in "Additional Resources" below.
Additional Resources
Contact for ACA Section 6401—Ordering, Referring, and Prescribing Provider Requirements
Phone
Open Monday–Friday 8 a.m.–5 p.m.
Fax
Address
| Last updated: | November 28, 2023 |
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