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The ACA Ordering, Referring, and Prescribing (ORP) Requirements for MassHealth Providers

The Affordable Care Act (ACA) Section 6401

The ACA ORP and MassHealth

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, and
  2. the ORP provider be enrolled with MassHealth as a fully participating provider or as a nonbilling provider.

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.

MassHealth and the ACA ORP Implementation

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.

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