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URGENT: Providers who refer, order or prescribe for Medi-Cal beneficiaries must enroll with DHCS



March 25, 2013
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement Practice Management 

The Department of Health Care Services (DHCS) made changes in January to its Medi-Cal provider enrollment requirements as a result of the Patient Protection and Affordable Care Act (ACA). One of the changes now requires all providers who order, refer or prescribe (including but not limited to physicians, NPs, and PAs) be enrolled in the Medi-Cal program. Previously, providers needed to enroll only if they wished to furnish (and bill for) covered services for Medi-Cal beneficiaries.


If an ordering and/or referring provider (ORP) is not enrolled in Medi-Cal, the "filling providers" (for example, the pharmacy that is filling the patient’s prescription or the specialist you are referring a patient to for treatment) will not be paid. As a result, patients may not receive needed items or services if the “filling providers” refuse to accept orders or referrals from providers who are not enrolled in Medi-Cal.


Although the new requirement took effect January 1, 2013, DHCS established a grace period to allow more providers to enroll before claims are denied. The grace period could end at any time and ORP providers are encouraged to complete the enrollment process as soon as possible.


ORP providers are providers who enroll for the sole purpose of ordering, referring or prescribing to covered beneficiaries and who do not directly submit claims for their services. Please note that this type of enrollment does not allow the Medi-Cal program to reimburse the ORP- only provider for services provided directly to Medi-Cal beneficiaries.


Providers who are already enrolled in Medicare or Medi-Cal under their individual (type 1) National Provider Identifier (NPI) number do not also have to enroll as ORP providers.


The providers that may be affected by this change include individual physicians or physicians employed by physician groups, federally qualified health centers, rural health clinics, critical access hospitals, the Department of Veterans Affairs, Department of Defense TRICARE program and the Public Health Service.


For more information, or to enroll as an ORP provider, visit the DHCS website. The ORP enrollment form is "DHCS 6129."


For questions regarding enrollment as an ORP provider, please contact the DHCS Provider Enrollment Division at pedcorr@dhcs.ca.gov or (916) 323-1945.

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