offered by

ACA Section 6401—Ordering, Referring, and Prescribing Provider Requirements

Section 6401(b) of the Affordable Care Act (ACA) includes requirements related to Ordering, Referring, and Prescribing (ORP) providers.

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
  • 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 121205
Boston, MA 02112-1205

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 (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 (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. Using staggered effective dates by provider type, MassHealth and the HSN will begin to deny claims for failure to comply with ORP requirements as follows:

Phase 1:

  • The NPI of the ORP provider is not included on the claim, or
  • The NPI of the ORP provider is included on the claim but the ORP provider is not an authorized ORP provider (see list above)

For dates of service on or after 12/15/19, such claims will be denied for the following provider types (Group 1):

  • Audiologist
  • Chiropractor
  • Clinical Nurse Specialist
  • Group Practices of the provider types on this chart
  • Hearing Instrument Specialist
  • Nurse Practitioner
  • Ocularist
  • Optician
  • Optometrist
  • Physician
  • Podiatrist
  • Psychologist
  • QMB Only Providers

 

For dates of service on or after 2/15/20, such claims will be denied for the following provider types (Group 2):

  • Abortion/Sterilization Clinic
  • Acute Inpatient Hospital**
  • Acute Outpatient Hospital**
  • Certified Independent Laboratory
  • Community Health Center**
  • Early Intervention
  • Family Planning Agency
  • Hospital-licensed Health Center**
  • Independent Diagnostic Testing Facility
  • Mental Health Center
  • Pharmacy (for claims processed through MMIS*)
  • Psychiatric Outpatient Hospital
  • Renal Dialysis Center
  • Substance Use Disorder Outpatient Hospital
  • Volume Purchaser

 

* Note that all claims processed by the Pharmacy Online Processing System (POPS) already require that the Prescriber NPI be included on the claims and be eligible to prescribe.

** Both MassHealth and HSN billing providers.

For dates of service on or after 4/15/20, such claims will be denied for the following provider types (Group 3):

  • Adult Day Health
  • Adult Foster Care
  • Chronic Outpatient Hospital
  • Competitive Bid Only (DMEPOS)
  • Durable Medical Equipment
  • Group Adult Foster Care
  • Group Practice (Therapist)
  • Home Health Agency
  • Independent Nurse
  • Orthotics
  • Oxygen and Respiratory Therapy Equipment
  • Prosthetics
  • Rehabilitation Center
  • Speech and Hearing Center
  • Therapist

For dates of service on or after 4/15/20, any/all impacted claims will be denied for failure to comply with the ORP requirements of Phase 1.

Phase 2:

  • The NPI of the ORP provider is included on the claim but the ORP provider is not actively enrolled with MassHealth.

For dates of service on or after 8/15/20, such claims will be denied for:

  • Group 1 provider types
  • Group 2 provider types
  • All claims processed by the Pharmacy Online Processing System (POPS)

For dates of service on or after 11/15/20, such claims will be denied for Group 3 provider types

For dates of service on or after 11/15/20, any/all impacted claims will be denied if the claim does not meet all three ORP requirements (ORP provider NPI on the claim, ORP provider is an authorized ORP provider type, ORP provider is enrolled with MassHealth).

MassHealth reserves the right to extend these timeframes, and will communicate any extensions through Message Texts and on the MassHealth and HSN websites.

For more information about the Ordering and Referring requirements see All Provider Bulletin 286: Start for Denials for Claims That Do Not Meet Ordering, Referring, and Prescribing Provider Requirements in "Additional Resources" below. 

Additional Resources for

Ordering, Referring, and Prescribing Provider Bi-Monthly Series

This webinar series offers an overview of the ordering, referring, and prescribing regulatory requirements and the completion of the MassHealth nonbilling enrollment contract and application. This session will provide helpful communication and educational tools to assist those provider types and services impacted by this regulatory change.

To enroll in a webinar session, please register at the MassHealth Learning Management System (LMS) to 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.

Click on "How to Enroll in a MassHealth ORP Webinar" in "Additional Resources," below, to learn more. 

Additional Resources for

Feedback