Author: Clinical Policy and Programs
In response to provider comments and questions regarding billing under the new federal Ordering, Prescribing and Referring (OPR) rules, North Carolina Medicaid is issuing this clarification for radiology and Independent Diagnostic Testing Facilities (IDTF).
According to Federal Regulation 42 CFR 455.410, any physician or other practitioner who orders, prescribes, refers, or renders services to North Carolina Medicaid or N.C. Health Choice (NCHC) beneficiaries must be enrolled in these programs. In compliance with 42 CFR 455.440, when required, the NPI of the physician or other professional who ordered or referred the service must be included on the claim.
Radiology claims for the technical component (TC Modifier) require an ordering NPI to be listed on a claim. This NPI must be the individual provider who ordered the test, not the group or facility. Medicaid will bypass the ordering provider edit when a radiologist is billing for professional services only (billed with modifier 26)
Radiology claims for the professional component (26 Modifier) do not require an ordering or referring provider NPI as the 26 modifier bypasses OPR editing. The ordering provider NPI is required when the service or supply was ordered by a provider who is different than the rendering provider for the service line. The NPI requirement applies to services provided by IDTF/Portable X-Ray providers and radiology global charges billed by an urgent care.
All NPIs submitted on a claim will be validated. If any NPIs listed are not enrolled in North Carolina Medicaid or NCHC, the claim will pend for 90 days and recycle daily to allow for provider enrollment. If the attending, rendering, ordering, prescribing or referring provider with the invalid NPI does not enroll within 90 days, the claim will deny.
If services are furnished to beneficiaries in another state, out-of-state providers are required to enroll with Medicaid or NCHC. Enrollment in another state’s Medicaid program does not exempt a rendering, ordering, prescribing or referring provider from enrolling with N.C. Medicaid or NCHC.
Billing providers should verify enrollment of ordering, prescribing or referring practitioners before services are provided. As of May 1, 2016, the “Enrolled Practitioner Search Function” is available on NCTracks provider portal. The Enrolled Practitioner Search provides the capability to validate provider information for billing, attending, referring, rendering, ordering and prescribing providers in Medicaid and NC Health Choice.
Note: The Enrolled Practitioner Search only includes individual providers who are actively enrolled in North Carolina Medicaid or NCHC on the date of inquiry. Information contained in the database is maintained by the individual provider and is subject to change daily. To access this feature, click on the Enrolled Practitioner Search button on the lower left side of the NCTracks Provider Portal home page. There is a Job Aid to assist providers under Quick Links on the Enrolled Practitioner Search page.
Clinical Policy and Programs
DMA, 919-855-4320