Federal Regulation Guidelines for Ordering, Prescribing or Referring (OPR) Providers

According to Federal Regulation 42 CFR 42 455.410, any physician or other practitioner who orders, prescribes, refers or renders services to a NC Medicaid Beneficiary must be enrolled in the NC Medicaid program. CFR 455.440 requires the National Provider Identifier (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 order, prescription or referral, the ordering, prescribing or referring provider must be enrolled in NC Medicaid.

Note: A streamlined application for is available through NCTracks for Ordering, Prescribing, or Referring providers that do not intend to render or bill services to NC Medicaid Rendering/Attending providers and Billing providers must be fully enrolled to receive payment for services.

Ordering Provider NPI is Required on the following Types of Claims:

• Home Infusion Therapy
• Private Duty Nursing
• Labs (non-hospital based)
• Independent Diagnostic Treatment Facilities (IDTF)
• Community Alternatives Program Services
• Immunizing Pharmacist
• Radiology/X-ray Procedures*
• Portable X-ray*
• Durable Medical Equipment (DME)

*Exception: Ordering NPI is not required when billing only the professional component (modifier 26) on the claim.

Referring Provider NPI is Required on the Following Types of Claims:

• Home Infusion Therapy
• Specialized Therapy – Outpatient and Independent Practitioners
• Hospice
• Home Health
• Private Duty Nursing
• Outpatient Hospital Clinics – Dialysis Facilities
• Community Alternatives Program Services

For more information on the requirement for Ordering and Referring NPI on CAP home and community-based services, please see the July 17, 2025 Medicaid Provider Bulletin. 

Additional Requirements

• Both the Ordering and Referring NPI submitted on the claim must be an individual, not an organization or group.
• Operating Provider NPI is required when an operating room revenue code is submitted.
• Service Facility NPI is required on Hospice claims when the member resides in a Nursing Facility.

If services are furnished to beneficiaries in another state, the out-of-state providers are required to enroll with NC Medicaid. Enrollment in another state’s Medicaid program does not exempt a billing, rendering, ordering, prescribing or referring provider from enrolling with NC Medicaid.

Billing providers should verify the enrollment of the individual rendering, ordering, prescribing or referring provider before services are rendered. The “Enrolled Practitioner Search” function is available on NCTracks provider portal for this purpose. This feature allows providers to inquire about other providers enrolled in NC Medicaid.

Additionally, the Enrolled Practitioner Search provides the capability to validate provider information for billing, attending, referring, rendering, ordering and prescribing providers.