NCTracks
Update on Enrollment Criteria for Ordering, Prescribing, and Referring Providers
42 CFR 455.410 requires that all Ordering, Prescribing and Referring (OPR) physicians - as well as other professionals providing services under the N.C. Medicaid, N.C. Health Choice (NCHC) or their respective waiver programs - be enrolled as participating providers. (See link below) This includes anyone who orders, refers, or prescribes services or items (such as pharmaceuticals) to N.C. Medicaid and NCHC beneficiaries and seeks reimbursement. Physician or non-physician practitioners who write orders, prescriptions or referrals must be enrolled in the N.C. Medicaid or NCHC and their individual NPI (not organizational NPI) must be included on the claim. This also includes providers directly contracted with the LME/MCOs.
Beginning Feb. 1, 2016, failure of an OPR provider to enroll in N.C. Medicaid or NCHC will result in claim denials. The billing provider will receive a denial with an EOB stating that the OPR provider is not enrolled.
Institutional, clinical and professional claims will deny if any of the NPIs on the claim are found to be providers who are not enrolled in N.C. Medicaid or NCHC. Providers should ensure that all ordering, prescribing and referring providers of the services for which they submit Medicaid or NCHC claims are enrolled in those programs.
As a reminder, effective July 1, 2015, all Institutional (UB-04/837-I) claims for Psychiatric Residential Treatment Facility (PRTF) services must include the name and NPI of the beneficiary's attending psychiatrist and billing provider for reimbursement. If the attending psychiatrist's NPI is not entered on the claim, the claim will deny with EOB Code 03101, "THE TAXONOMY CODE FOR THE ATTENDING PROVIDER IS MISSING OR INVALID." Please refer to the April 2015 Medicaid Bulletin.
If services are furnished to beneficiaries in another state, the out-of-state providers are required to enroll with N.C. Medicaid or NCHC. Enrollment in another state's Medicaid program does not exempt an OPR provider from enrolling with N.C. Medicaid or NCHC. More information for OPR professionals can be found on the N.C. Division of Medical Assistance (DMA) Provider Enrollment web page.
Providers with questions about the NCTracks online enrollment application can contact the CSC Call Center at 1-800-688-6696 (phone); 919-851-4014 (fax) or NCTracksprovider@nctracks.com (email).