Ordering, Prescribing or Referring and Rendering Provider Requirements for Local Education Agency Claims

This information applies specifically to NC Medicaid Direct, as services billed by Local Education Agencies (LEAs) remain carved out of NC Medicaid Managed Care.

NCTracks is North Carolina’s multi-payer Medicaid Management Information System (MMIS) and claims processing platform, operated by the North Carolina Department of Health and Human Services (NCDHHS).

To comply with federal regulations, the ordering, prescribing or referring (OPR) National Provider Identifier (NPI) is required on claims for services that are ordered/prescribed or referred, and must be an individual that is actively enrolled in NC Medicaid (42 CFR § 455.440 and 42 CFR § 455.410). Physical and Occupational Therapy services must be ordered/prescribed and Speech-Language Pathology and Audiology Therapy services must be referred (42 CFR § 440.110).

For dates of service on or after July 1, 2026, LEA claims submitted to NCTracks must include:

• OPR NPI: Enter the individual OPR NPI in both the ordering and referring provider fields. 
• Rendering NPI: Enter the NPI of the rendering provider in the rendering provider field.

Per 2023 Centers for Medicare & Medicaid Services (CMS) Guidance, eligible providers must enroll in NC Medicaid and the NPI must be included on LEA claims. If a provider type is not eligible to enroll in NC Medicaid (e.g., North Carolina Department of Public Instruction licensed School Psychologists), the LEA’s NPI may be listed as the rendering provider. 

All LEA covered services in NC Medicaid Clinical Coverage Policy (CCP) 10C must be ordered. In some cases, the same individual may serve as both the OPR and rendering provider. 

Enrollment in another state’s Medicaid program does not exempt a billing, OPR or rendering provider from enrolling with NC Medicaid.

The “Enrolled Practitioner Search” function is available on the NCTracks Provider Portal to validate NPI information for billing, OPR and rendering providers.

Contact

• NC Medicaid Contact Center: 888-245-0179
• NC Medicaid School-Based Services Team: Medicaid.SchoolBasedServices@dhhs.nc.gov
• NCTracks: 800-688-6696 or email: NCTracksprovider@nctracks.com