Providers were notified on June 20, 2025, and July 3, 2025, in NCTracks about the requirement to include the Ordering and Referring Provider (OPR) National Provider Identifier (NPI) on their billing claims.
This requirement is outlined in Federal Regulation 42 CFR 42 455.410, which requires the NPI of any ordering or referring physician or other professional to be specified on any claim for payment. To be reimbursed for services or supplies resulting from a practitioner's OPR, the OPR provider must be enrolled in NC Medicaid.
Community Alternatives Program (CAP) claims submitted for processing on and after June 15, 2025, had to meet the requirements described above for the proper adjudication of those claims.
Effective July 3, 2025, claims submitted for the Community Alternatives Program for Children and Disabled Adults (CAP/C and CAP/DA) without the ordering or referring physician NPI will be adjudicated with a pay status. The implementation of pay and report allows providers extra time to update their electronic billing systems to comply with CFR 455.440. This is a federal mandate, and NC Medicaid must comply.
An assessment of provider readiness will be conducted in Oct. 2025. An announcement will be posted in advance of the period when NCTracks will conclude the pay and report and switch back to a denial status resuming non-payment when the ordering and referring NPIs are not included in the claim.
For more information, please see the June 20, 2025, and July 3, 2025, NCTracks announcements.
Contact
If you have any questions about the reconsideration, please call the NCDHHS Hearing Office at 1-919-814-0090 or the NCTracks call center at 1-800-688-6696.