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Providers Must be Enrolled in NYS Medicaid Program to ORDER/PRESCRIBE/REFER/ATTEND Medicaid Services - Including Providers in Managed Care Plans as of Jan. 1, 2018

What types of providers are affected?

Effective January 1, 2014, medical providers must be enrolled with the NY State Medicaid program in order for Medicaid to pay for services that they prescribed, ordered or referred.   The rule applies to ordering, prescribing, referring and attending physicians and healthcare providers (“OPRA Providers”). 

Effective January 1, 2018, medical providers that contract with Medicaid managed care plans  and all Child Health Plus providers must also enroll in the NYS Medicaid Program.  See NYS Medicaid Update May 2017, page 6.

What Medicaid programs are affected?

This rule applies in both Medicaid fee-for-service and waiver programs, and as of January 1, 2018, also to services provided by a managed care plan.  

What services are affected?

The provider must enroll before ordering, prescribing, or referring services, including asking for prior authorization of a prescription.  The service must be within the provider’s scope of practice to order, prescribe, or refer and all other program rules for seeking coverage apply. 

Services affected by this new rule include home care services, lab testing, and prescription drugs, including asking for “prior authorization” of a prescription.    This includes doctors signing a physician's order or M11q for Personal Care services including Immediate Need services

EXAMPLE:  If a Medicaid beneficiary uses her blue Medicaid card at the pharmacy counter, meaning she has fee-for-service prescription coverage, the prescriptions will not be paid for by Medicaid unless the doctor who prescribed the drugs is enrolled in NY State Medicaid.  

Can a provider retroactively enroll?

There is no retroactive enrollment, although applications received before March 31, 2014 should have had a January 1, 2014 effective date. 

How long does enrollment take?

Enrollments are processed within 30 days of receipt of application.  

Does this affect practitioners already actively enrolled in Medicaid?

Practitioners already actively enrolled in the Medicaid program do not need to enroll as OPRA Providers. 

Are OPRA Providers mandated to accept Medicaid patients?

NoThey may enroll as a non-billing, Ordering/Prescribing/Referring/Attending (OPRA) provider.

Do attending providers (e.g.: registered nurses and other health care professional support staff) need to enroll?

Generally, attending providers are not ordering or referring services, so they do not need to enroll. However, an attending provider in the absence of an ordering or referring provider may need to enroll as an ordering or referring provider in order to obtain Medicaid coverage for a claim. Note that if these staff members are reported in the Attending provider field on a claim for Medicaid coverage, the medical practitioner who is responsible for ordering/referring should be reported in the Referring provider field.

I am a provider who does not have a National Provider Identification number (NPI). How can I enroll?

“Atypical” providers under Waiver Programs such as Home and Community Based Services (HCBS), Nursing Home Transition and Diversion (NHTD), Traumatic Brain Injury (TBI), and Care at Home (CAH) who cannot obtain NPI numbers can enroll as OPRA Providers using their Medicaid Management Information System (MMIS) provider ID.  

I am a provider who cannot order services under the School Supportive Health Service Program. Do I need to enroll?

Physical therapists and occupational therapists who cannot order services under the School Supportive Health Service Program do not need to be OPRA Providers, but speech language pathologists so ordering, do.

How can I find an OPRA Provider?

Enrolled OPRA Providers can be searched for through https://www.emedny.org/info/opra.aspx. Searching by NPI number is best, although searching by name is possible. Find NPI numbers at: https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistrySearch.do?subAction=reset&searchType=ind.

How can I enroll as an OPRA Provider?

Go to: https://www.emedny.org/info/ProviderEnrollment/index.aspx.  There will be periodic revalidation of OPRA Providers. Here is direct link for providers who do not want to bill Medicaid, but only want to prescribe, order, or make referrals for Medicaid recipients.

To check on enrollment status a provider can call 1-800-343-9000.   Practitioners may also check
the Enrolled Practitioners Search function at: https://www.emedny.org/info/opra.aspx.

Additional Q&A about the OPRA program can be found at: https://www.emedny.org/Notice/DEC2013_MEDUPDATE-OPRA.pdf. Questions specific to pharmacy, Office for People with Developmental Disabilities (OPWDD), Office of Mental Health (OMH), Office for Alcohol and Substance Abuse Services (OASAS), Early Intervention, and School Health programs are answered in that Medicaid Update.


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