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Ordering/Referring Provider Now Required on Some Claims

December 13, 2013

Per bulletin OHCA 2013-44 from the Oklahoma Health Care Authority (OHCA), some provider types will now be required to provide the National Provider Identifier (NPI) of the ordering/referring physician when submitting claims for reimbursement.  This requirement is set to go into effect on January 1, 2014.  A copy of the bulletin is attached for review, and lists the provider and specialty types to whom this requirement applies (including Home Health, Durable Medical Equipment (DME), Therapist, Specialty Home Nursing Services and others).

After discussion with OHCA, it appears that ADvantage Nursing/ADvantage Skilled Nursing billing type (16) is exempt from this requirement.  The Therapist billing type (17) will be affected, however as a physician’s prescription is currently required for this service, obtaining the NPI of that physician should present little difficulty.

The provider type that is anticipated to be impacted most by the new requirement is the DME billing type (25).  For some ADvantage-covered equipment and supplies, such as bathroom equipment and incontinence supplies, a physician’s prescription has not been and is still not required for authorization.  However it now appears that DME providers will be required to have a prescribing physician’s NPI in order to submit claims for these items.  As all claims submitted by DME providers will be denied without the NPI beginning January 1, there is potential that items with monthly delivery (such as incontinence supplies) may be held until a physician’s order has been received.  New DME authorizations may also be impacted. 

Case Managers are advised to assess their caseloads and to facilitate their Members obtaining the necessary prescriptions so service delivery is not disrupted.  Communication between Case Managers and DME providers is essential during this period of transition.

If you have any questions regarding the information provided above, please feel free to contact us via Smarter Mail at:

Thank you.

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