Enrollment of Ordering, Referring and Prescribing Providers

As required by the ACA and implementing regulation, all practitioners, including those who order, refer or prescribe items or services for MA beneficiaries, must enroll in the MA Program. In processing claims submitted in a format that includes a field for the ordering or referring provider, the Department will use the National Provider Identification (NPI) number submitted on the claim to validate the enrollment of providers in the MA Program. Beginning April 1, 2016, PROMISe™ will return an informational message to remind providers about the requirement that the ordering, referring or prescribing provider must enroll in the MA Program. The informational message will state the ordering, referring or prescribing provider is “not on file”. “Not on file” means that the NPI entered on the claim does not match the NPI of an enrolled MA provider. Beginning September 25, 2016, the claims will be denied if the ordering, referring or prescribing provider is not enrolled in the MA Program.