Jan. 1 Effective Date for Ordering/ Referring Editing Initiative
Introduction
Under new federal requirements, the Department of Health (DOH) is implementing new claims edits that will require any prescribing professional (including MDs, nurse practioners, and physicians’ assistants) to be enrolled as a Medicaid provider in order for drugs, equipment, supplies and services to be reimbursed under the Medicaid Fee-for-Service (FFS) program. The new claims edits will be effective as of Jan. 1, 2014.
- For example, with new edits in place if the prescriber of drugs in a nursing home is not enrolled as a Medicaid provider, those claims will reject for payment if billed under Medicaid FFS. In this scenario, the vendor pharmacy will not be able to obtain payment for those drugs. This in turn could negatively impact the ability of the nursing home to obtain drugs from the vendor pharmacy.
DOH has been doing test runs of how the new edits will work, and their data indicate that there are still a significant number of FFS claims that would reject once the system goes live. The majority of these would be prescription drug claims, but claims for any durable medical equipment, supplies or other prescribed services billed under Medicaid FFS would also be rejected.
More information on the new edits is available at http://www.emedny.org/, along with recent Medicaid Update articles (also available at eMedNY).
LeadingAge New York is sharing this information broadly so that all members, even those not directly impacted, can be advocates for their consumers and help ensure that there is no disruption in obtaining necessary Medicaid coverage.
Most Recent Guidance
The most recent guidance from DOH can be found in the October 2013 Medicaid Update and reads:
Ordering/Referring Editing Implementation in Fee-for-Service Medicaid
The Affordable Care Act (ACA) and subsequent federal regulations (42CFR 455.410) requires enrollment for physicians and other healthcare professionals ordering/referring services provided under the Medicaid state plan or under a waiver of the state plan. It does not apply to services paid through a Medicaid managed care plan.
The October 1, 2013, implementation of new claims editing requiring Medicaid enrollment for Ordering/Prescribing/Referring/Attending (OPRA) physicians and healthcare professionals has been delayed until Jan. 1, 2014.
The extended implementation will allow for more time for OPRA providers to request and obtain enrollment. Providers who have submitted enrollment applications will be notified by letter when a determination has been made or if the application was missing information. Providers who have not yet submitted enrollment applications must do so immediately to avoid future interruption of the services they order for their patients.
To determine if a physician or healthcare professional is enrolled in Medicaid, use the search feature available here: https://www.emedny.org/info/opra.aspx
Provider Enrollment forms and instructions: https://www.emedny.org/info/ProviderEnrollment/index.aspx
Provider Enrollment assistance and status checks:
Please call the eMedNY Call Center at (800) 343-9000
OPRA Frequently Asked Questions:
https://www.emedny.org/info/ProviderEnrollment/ProviderMaintForms/Core_OPRA_FAQs.pdf
For updates on OPRA implementation, sign up for eMedNY General Updates via e-mail LISTSERV® at: https://www.emedny.org/Listserv/eMedNY_Email_Alert_System.aspx
Additional DOH guidance includes:
DOH notice on impact on pharmacy claims.
Some Additional Facts
In a teleconference with DOH, associations were asked to remind members about this initiative, and if they are at all uncertain about a prescribing professional’s Medicaid enrollment status, they should double check using the search feature highlighted in the above Medicaid Update article. If a prescriber is not currently enrolled the search will return no results.
If a prescriber confirms they are not an enrolled Medicaid provider she/he can enroll on-line using the Provider Enrollment forms and instructions also linked in this article. DOH cautions that there is approximately a thirty-day turn around on applications submitted with no errors or omissions. Providers needing to enroll should carefully review the instructions and forms and ensure that everything is complete and accurate. The most problematic area in completing the enrollment forms is the disclosure of associated and controlling interests relative to the prescriber’s employer. Failure to complete this section accurately is the most frequent cause of application rejections. A rejection could extend the enrollment process well beyond thirty days.
Enrollment also requires that the professional (including MDs, nurse practioners, and physicians’ assistants) have a current NPI number and DEA certificate.
Drugs, equipment, supplies and services provided under managed care (both MLTC and mainstream programs) and included in the managed care benefit package are not impacted by the new claims edits. However, if a Medicaid managed care enrollee is prescribed anything outside the managed care benefit package these claims will be subject to the new edits.
Orders carried over from a hospital prescriber to a nursing home or home care provider will also reject if the hospital prescriber is not enrolled in the Medicaid program.
Prescriptions written by non-Medicaid enrolled professionals remain valid and can be honored. However, payment cannot be made for those claims under the Medicaid FFS program. The real concern is that a vendor may refuse to provide goods or services if the Medicaid FFS payment is not allowed. Providers, prescribers, and vendors need to be communicating on this issue and ensuring that the new edits will not result in any interruption of drugs, supplies or services to Medicaid FFS recipients.
Conclusion
Again, DOH remains concerned that their test runs are indicating that, especially in the area of nursing home prescription drug claims, the number of rejections remains unacceptably high. DOH is expecting to release a special edition Medicaid Update this week. In the meantime, with the Jan.1 deadline looming, providers should be checking to ensure that all necessary prescribers are enrolled in the Medicaid program to avoid any potential interruption in goods or services to their Medicaid FFS recipients.
Please contact me with any questions at pcucinelli@leadingageny.org or 518-867-8827.