August 30, 2013

State of Alabama
Press Release: Medicaid

Ordering/Referring Provider’s NPI Must Be Present on Claims

TO:  Independent Laboratories, Independent Radiologists, Durable Medicaid Equipment, Home Health, Physicians, Physician Assistants, Certified Nurse Midwives, Certified Nurse Practitioners, Psychologists, Optometrists, Dentists, Podiatrists

Effective October 1, 2013

Code of Federal Regulations (42 CFR 455.440) requires all claims for the payment of items and services that are ordered, referred, or prescribed to contain the National Provider Identifier (NPI) of the physician or other professional who ordered, referred, or prescribed such items or services.


Effective for claims received on or after October 1, 2013, all Medicaid claims from laboratories, imaging centers, home health agencies, and durable medical equipment providers MUST have the NPI of the ordering/referring provider.


There are three basic requirements:

1.  The physician or non-physician practitioner must be enrolled in Medicaid as either a regular Medicaid provider or as an OPR provider. 

2.  The NPI used must be for an individual physician or non-physician practitioner and cannot be an organizational NPI.

3.  Interns and non-licensed residents must use the NPI of the teaching, admitting, or supervising physician on the claim for reimbursement. If the resident has a medical license, then the resident must be enrolled with Medicaid and the NPI of the resident must be used on the claim for reimbursement.


Attention Physicians and Non-physician Practitioners:

You must furnish your NPI on all orders/referrals for laboratory, imaging services, home health services, and durable medical equipment.  The laboratory facility, the radiology/imaging center, the pharmacy, the home health agency, and the medical supply company will always need the NPI of an ordering/prescribing/referring physician or non-physician practitioner in order to submit their claims for payment to the Medicaid program.


An enrollment application is available for those providers who do not treat Alabama Medicaid recipients for payment, but who do order, prescribe, or refer.  These providers will be enrolled as an OPR provider.  Medicaid will not make payment to an OPR provider but will recognize their NPI for services rendered by participating Medicaid providers.  An abbreviated enrollment application is located on the Alabama Medicaid Agency website at the following link in the Administrative Forms section: 


Providers can check to see if an ordering or referring provider is enrolled with Medicaid through the Medicaid Secure Website.  Providers may search using an NPI or license number of a provider.  This is available on the Providers/Provider Search tab using the following link.

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