CAMPS has participated in a series of stakeholder discussions with DHCS over upcoming changes to the provider enrollment process that might impact you in multiple ways. Most of the changes described below are actually mandated by Congress through the ACA adopted several years ago that require all Medicaid programs to institute specific requirements in the provider enrollment and claims payment process to reduce fraud and abuse. Some of the changes will impact the provider enrollment process, such as application fees, criminal background and fingerprint requirements, and revalidation of all providers. Most of those take effect for all new applications beginning in 2013. There are increased levels of scrutiny for provider types based upon their perceived level of risk for fraud and abuse. In case you hadn't figured it out yet DME is in the highest risk category.
We will be providing additional information in the coming months and you will also find some notices in Medi-Cal Provider Bulletins or on the Provider Enrollment website. We wanted to alert you to changes regarding ordering/referring and prescribing providers that will take effect on 1/1/13. The Medi-Cal must require that any health care provider who orders/refers or prescribes any service must be enrolled in the program. Currently there are some providers who are not enrolled and do not bill for their specific services to Medi-Cal beneficiaries. The physician may not have their own unique NPI number or be enrolled at all. The notice detailed below indicates that effective next year an ancillary service provider will not be reimbursed for a service provided to a Medi-Cal enrollee if the ordering practitioner is not enrolled in either Medi-Cal or Medicare. The edits to deny payment will not be implemented for some time, up to one year, and there is a short form and fast track to enroll these practitioners once they apply. Please review the information below:
Medi-Cal Requirement for Ordering/Referring/Prescribing Providers Forms and Procedures
In accordance with the Centers for Medicare and Medicaid Services (CMS), the Department of Health Care Services (DHCS) is establishing the requirement for the Medi-Cal program to enroll ordering, referring or prescribing only providers in accordance with 42 Code of Federal Regulations (CFR) Section 455.410 and 42 CFR Section 455.440. These requirements are necessary to comply with the February 2, 2011, Final Rule published by CMS in the Federal Register (42 CFR Parts 405, 424, 447 et al., 76 Federal Register 5862-5971 [Feb. 2, 2011]), which implements provisions of the Affordable Care Act (ACA) of 2010.
Based upon the authority granted to the DHCS director in the Welfare and Institutions (W&I) Code, Section 14043.75(b), the director has authorized the following forms and established the procedures and criteria governing their use. These procedures are regulations implementing the W&I Code, Section 14043.1(b) & (o) and Section 14043.15(b)(3) and have the full force and effect of law. The Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement for Physician and Non-physician Practitioners (DHCS 6219) as well as the procedures governing their use are effective on January 1, 2013.
Background and overview of the new requirement
Traditionally, most providers have enrolled in the Medi-Cal program to furnish covered services to Medi-Cal beneficiaries. However, with the implementation of the ACA, some providers will need to enroll in the Medi-Cal program for the sole purpose of ordering, referring or prescribing services for Medi-Cal beneficiaries. These providers do not send direct claims to Medi-Cal for the services they furnish.
Please note that this type of enrollment does not allow the Medi-Cal program to reimburse the ordering, referring or prescribing only provider for services provided directly to Medi-Cal beneficiaries.
Federal Medicaid Regulations 42 CFR 455.410(b) provides that the State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan to be enrolled as participating providers. 42 CFR 455.410(c) provides that the State Medicaid agency may rely on the results of the provider screening performed by any of the following: (1) Medicare contractors, (2) Medicaid agencies or (3) Children's Health Insurance Programs (CHIP) of the States. Lastly, 42 CFR 455.440 provides that the State Medicaid agency must require all claims for the payment for items and services that were ordered or referred to contain the National Provider Identifier (NPI) of the physician or other professional who ordered or referred such items or services.
Effective January 1, 2013, W&I Code, Section 14043.1(b) & (o) require the enrollment of ordering, referring and prescribing providers as participating providers in the Medi-Cal program. W&I Code, Section 14043.15(b)(3) provides that the NPI of the ordering, referring and prescribing provider must be listed on the claims for reimbursement.
Requirements
There are three basic requirements for ordering, referring or prescribing for Medi-Cal beneficiaries:
1. The physician or non-physician practitioner must be enrolled in Medicare or Medi-Cal.
2. The ordering, referring or prescribing provider NPI must be for an individual physician or non-physician practitioner (not an organizational NPI).
3. The physician or non-physician practitioner must be of a specialty type that is eligible to order, refer and prescribe in accordance with law and the physician and non-physician practitioner's Practice Act.
Procedures for Enrollment of Ordering, Referring or Prescribing Only Providers
Unless otherwise provided, if the provider is already enrolled in Medicare or Medi-Cal as an individual with their Type 1 NPI, they are not required to enroll in Medi-Cal for the sole purpose of ordering, referring or prescribing.
If the provider is not currently enrolled in Medicare or Medi-Cal as an individual with their Type 1 NPI, and they wish only to be able to order, refer or prescribe items or services for Medi-Cal beneficiaries and not seek reimbursement for services provided directly to Medi-Cal beneficiaries, they must enroll as an ordering, referring or prescribing only provider. In order to enroll in the Medi-Cal program for the sole purpose of ordering, referring or prescribing providers must submit the Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement for Physician and Non-physician Practitioners (DHCS 6219).
Failure to Enroll
If the ordering, referring or prescribing provider's name or NPI on the claim of the billing provider is not enrolled in the Medi-Cal program or Medicare, the claim will not be paid.
Review Timeframes
DHCS has 90 days to review Medi-Cal ordering/referring/prescribing provider applications from physicians or osteopathic physicians pursuant to W&I Code, Section 14043.26(g) and notify the applicant of the action DHCS will take.
DHCS has 180 days to review Medi-Cal ordering/referring/prescribing provider applications from non-physician practitioners pursuant to W&I Code, Section 14043.26(f) and notify the applicant of the action DHCS will take.
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