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Elizabeth M. Whitehorn, Director

Provider Notice Issued 11/09/2018

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Date:   November 9, 2018

 

To:       All Medical Assistance Program Providers

 

Re:      Ordering, Referring, Prescribing - National Provider Identifier (NPI) Requirements

 

 

 

 

 

 

This notice informs providers that effective with dates of service on and after January 1, 2019, the Department of Healthcare and Family Services (HFS) is requiring all claims for services that require an ordering or referring practitioner contain the name and National Provider Identifier (NPI) of the practitioner who ordered, referred, or prescribed such services. This requirement also applies to claims where Medicare is the primary payer.

 

Initially, providers will receive an informational message when a claim requiring an ordering or referring physician or other professional (ORP) has been submitted without the required information. The pharmacy point-of-sale claims processing system currently returns an informational message when a claim is submitted and the prescriber identified on the claim is not enrolled with the Department.

 

Effective with dates of service on and after January 1, 2019, if the ORP’s name and NPI are not on the claim or if the claim contains information for an ORP who is not enrolled, the claim will reject and the provider will not receive reimbursement for services. At that time, the Department will also begin rejecting pharmacy claims where the prescriber identified on the claim is not enrolled.

 

The ORP must be enrolled through Illinois Medicaid Program Advanced Cloud Technology (IMPACT) as a participating Physician, Dentist, Optometrist, Podiatrist, Advanced Practical Nurse, or a Physician Assistant. Local Education Agencies (LEA) should refer to the October 18, 2016 Provider Notice for additional information regarding prescription/order or referral of services being rendered in the school setting.

 

ORP providers must retain all documentation to support services ordered, including the establishment of medical necessity for the services or supplies. Billing providers should verify the enrollment of the ORP before services are provided.

 

Pharmacy Point of Sale Submittal Requirements

Refer to the Department’s NCPDP Payor Sheet for specific instructions regarding submission of prescriber identifying information.

 

Hospital UB-04 Submittal Requirements

Form Locators 78/79: For general, psychiatric, and rehabilitation hospitals, Provider Type Qualifier Code DN followed by the Referring Provider NPI is required on all outpatient claims except when a claim contains Emergency Room Revenue Code 0450, 0451 or 0456.

 

 

Institutional Electronic Claim Submittal Requirements

Refer to the 837I Implementation Guide.

 

Non Institutional Practitioners (NIPS):

Non-Institutional practitioners must report the ORP in the following situations:

 

The ORP is required when a practitioner evaluates a participant with respect to a diagnosis or treatment at the request of another practitioner (referring) when the following providers bill a consultation code:
  • Physician
  • FQHC, ERC, RHC
  • Advanced Practice Nurse
  • Podiatrist

The ORP is required when the service is rendered in a long term care facility and the Place of Service Code is 31, 32, or 33 when billed by the following providers:     

  • Optometrist (required when a consultation and procedure code is between 99201-99499)
  • Podiatrist

The ORP is required on all claims for the following providers:
  • Physical Therapist
  • Occupational Therapist
  • Speech Pathologist
  • Audiologist
  • LEA (when billing OT, PT, Speech, Audiology)
  • Home Health Agency
  • Community Health Agency
  • Home Nursing Agency
  • Hospital Billing fee-for-service
  • Durable Medical Equipment and Supplies
  • Independent Diagnostic Testing Facilities
  • Independent Laboratory
  • Imaging: Portable X-ray
  • Imaging Centers
  • Optical Supply Companies
  • Certified Health Department

 

NIPS Electronic Claim Submittal Requirements

Refer to the 837P Implementation Guide.

 

NIPS Paper Claim Submittal Requirements

When billing on paper, non-institutional providers must report the ORP in the appropriate fields. Further information can be found in the Chapter 200 appendix of the specific provider handbook.

Claim Form

Field Number

Field Description

1443 Provider Invoice

10

21

Referring Practitioner Name (First, Last)

Ref. Prac. No.

2210 Medical Equipment/Supplies Invoice

8

Service Sections- Ordering Practitioner Name (First, Last) Ord. Prac. No.

2211 Laboratory/Portable X-Ray Invoice

12

13

Referring Practitioner Name (First, Last)

Ref. Prac. No.

2212 Health Agency Invoice

12

13

Referring Practitioner Name (First, Last)

Ref. Prac. No.

2360 Health Insurance Claim Form

19

Name of Referring Physician or Other Source and Provider Number (NPI)

3797 Medicare Crossover Invoice

25

26

Name of Referring Physician or Facility

Identification Number of Referring Physician

 

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.

Teresa T. Hursey

Medicaid Director