Author: Provider Services
Note: This article was originally published as a Special Bulletin in January 2018, with updates regarding clinical pharmacist practitioners.
In response to provider feedback, the use of the NPI Exemption List for residents and interns enrolled in graduate dental and medical programs and area health education centers will be extended through Aug. 31, 2018.
Clinical Pharmacist Practitioners (CPPs)
Effective July 29, 2018, Clinical Pharmacist Practitioner (CPP) taxonomy code 1835P0018X will be added to allow in-state, border and out-of-state individual Medicaid/Health Choice providers to enroll in NCTracks. CPPs will be authorized to act as an ordering, prescribing, referring (OPR) or rendering provider working under the direction or supervision of a licensed physician. For the supervising physician (or the organization employing the supervising physician and the CPP) to bill for the services provided by the CPP, the CPP must complete the full enrollment application to be listed as the rendering provider on a claim. The services provided by the CPP can NOT be billed as incident to the physician. Therefore, CPPs must complete the individual application (full enrollment) instead of the OPR Lite abbreviated application.
Required licensure and certification for the CPP taxonomy are:
- Full and unrestricted license to practice as a pharmacist in North Carolina or the state in which the provider resides, and,
- Full and unrestricted certificate to practice as a CPP in North Carolina.
Out-of-state providers must be certified to practice as a CPP according to the rules of the state in which they practice.
The following enrollment requirements will apply:
- $100 application fee
- Credentialing and criminal background checks
- Re-credentialing every five years, and,
- Manage Change Request (MCR) submission to update or end date the provider record
Note: The NPI Exemption List deadline is Aug. 31, 2018. CPPs are encouraged to begin the enrollment process on July 30, 2018.
Per 21 N.C.A.C. 46.3101, a CPP is approved to provide drug therapy management, including controlled substances, under the direction or supervision of a licensed physician only.
If a claim is submitted with a CPP's NPI and taxonomy as the billing provider, the claim will be denied with Explanation of Benefits (EOB) 01877 - PROVIDER IS NOT AUTHORIZED TO ACT AS A BILLING PROVIDER.
Residents and Interns
Residents and interns licensed through the NC Medical Board and NC Dental Board with a resident in training license (RTL) may enroll as OPR lite providers via the abbreviated application in NCTracks. These practitioners will use the taxonomy 390200000X, Student Health Care, when enrolling as an OPR lite provider.
The services of residents or interns in a Graduate Medical Education teaching setting are not billable to Medicaid. Therefore, residents and interns who order services, prescribe medications or services or make referrals must provide their NPI (if enrolled) or their supervising physician’s NPI to the provider to whom they submitted an order, made a referral or prescribed medications or services. The supervising physician may bill for the services they personally provided during the patient encounter.
General Guidelines
The following enrollment requirements apply to OPR lite providers:
- $100 application fee
- Credentialing and criminal background checks including fingerprinting, if applicable
- Manage Change Request (MCR) submission to update or end date the provider record
- Revalidation every five years, and,
- MCR to change from an OPR lite enrollment provider to a fully enrolled provider if they meet the full enrollment criteria and are to be reimbursed for claims.
Note: OPR lite providers may request a retroactive effective date up to 365 days preceding the date of application.