This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
This bulletin updates the information in the September 2016 Ordering, Prescribing, or Referring Special Bulletin. Effective for dates of service billed on and after Sept. 1, 2024, hospital outpatient claims submitted to NCTracks for physical therapy, occupational therapy, speech therapy and audiology services must include the National Provider Identifier (NPI) of the Ordering, Prescribing, or Referring (OPR) provider. The OPR provider must be enrolled in NC Medicaid.
Per federal regulations, the OPR NPI is required to be on claims for services that are ordered or referred, the OPR must be enrolled in NC Medicaid, and outpatient specialized therapy services must be prescribed or referred (42 CFR § 455.440, 42 CFR § 455.410 and 42 CFR § 440.110).
For dates of service billed on or after Sept. 1, 2024, hospital outpatient claims submitted to NCTracks must include the referring provider NPI when the rendering provider taxonomy is 225100000X Physical Therapist, 225X00000X Occupational Therapist, 235Z00000X Speech-Language Pathologist, or 231H00000X Audiologist.
Per NC Medicaid Clinical Coverage Policy 10A, medically necessary outpatient specialized therapies services are covered when the service is ordered by a Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Doctor of Podiatric Medicine (DPM), Certified Nurse Midwife (CNM), Physician Assistant (PA), or Nurse Practitioner (NP) and when prior authorization is received. Prior authorization is not required for evaluations. Prior approval does not guarantee payment.
This federal requirement applies to NC Medicaid Direct and NC Managed Care health plans. Refer to NC Managed Care health plans for claims instructions for beneficiaries enrolled in NC Managed Care.
Contact
NC Medicaid Contact Center, 888-245-0179
NC Managed Care health plans