Ordering, Prescribing, or Referring for Medicaid Beneficiaries? Be Sure You’re Enrolled in Medicaid

Physicians and practices that bill the Medicaid Fee-for-Service Program – known as Medical Assistance (MA) in Pennsylvania – should be aware that claims for dates of service on or after April 3, 2017, will be denied if the ordering, preferring, or prescribing provider is not enrolled in the MA program. Such claims will be denied even if the billing provider is enrolled in MA.

In an April 17 update to billing providers, Pennsylvania's Department of Human Services (DHS) confirmed that claims must contain the National Provider Identifier (NPI) of the MA-enrolled ordering, referring, or prescribing clinician. DHS uses the NPI number on the claim to validate the provider's enrollment in the MA Program. 

All Medicaid practitioners, including those who order, refer or prescribe items or services for MA beneficiaries, must enroll in the MA Program. This requirement applies even if those providers do not submit claims to the state Medicaid program for Medicaid-covered services rendered to Medicaid beneficiaries.

Examples of services that require a prescription, an order, or a referral include:

  • All medications
  • Medical supplies, medical equipment, orthotics, and prosthetics
  • Lab tests
  • Home health services
  • Radiologic imaging services
  • Hospital admissions
  • Procedures done in a hospital short procedure unit (SPU), an ambulatory surgical center, or a treatment room

DHS offers detailed guidance on which claims require the NPI number of a MA-enrolled ordering, referring, or prescribing clinician. Access it here.

How to Find Out If a Clinician Is Enrolled in MA

If you're not sure if a clinician is enrolled in MA, you can log into the PROMISe™ internet portal and then access the "Medical Assistance Enrolled Provider Portal Lookup." Billing providers who discover that an orderer, prescriber, or referrer is not enrolled in MA may want to let the beneficiary know and also ask the clinician to enroll in the MA program. This will help to prevent any treatment disruption.

Questions? Contact the DHS Program Office at 1-800-537-8862 with any questions or concerns. Pennsylvania Medical Society (PAMED) members can also contact PAMED's Knowledge Center at 855-PAMED4U (855-726-3348) or KnowledgeCenter@pamedsoc.org.

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