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Elizabeth M. Whitehorn, Director

Provider Notice issued 09/04/2024

 

To:
 Enrolled Independent Laboratories; Pharmacies, Physicians, Advanced Practice Registered Nurses (APRNs); Physician Assistants (PAs); Encounter Rate Clinics (ERCs); Federally Qualified Health Centers (FQHCs); Rural Health Clinics (RHCs); and Local Health Departments
​Date September 4, 2024
​Re:
 Medical Necessity for COVID-19 Testing and Confirmation of Ordering/Referring/Prescribing (ORP) National Provider Identifier (NPI) Requirements

This notice provides clarification related to medical necessity for COVID-19 testing and confirms ORP billing requirements for that testing. These issues apply to Medicaid fee-for-service (FFS) and HealthChoice Illinois managed care organization (MCO) claims.

Per 89 Ill. Admin. Code Section 140.2, “necessary medical care” is that which is generally recognized as standard medical care required because of disease, disability, infirmity or impairment. The Department of Healthcare and Family Services (HFS) did not develop specific medical necessity criteria for COVID-19 testing at the time testing became available, but all medical care provided to Medicaid-eligible customers must be justified.

As noted in the SHO #21-003 Medicaid and CHIP Coverage and Reimbursement of COVID Testing guidance:

“CMS interprets these amendments [to the American Rescue Plan] to require states to cover, without cost sharing, all diagnostic and screening testing that would be consistent with the Centers for Disease Control (CDC) recommendations. This includes, for example, coverage of screening testing to return to school or work or to meet travel requirements.”

ORP NPI billing requirements were outlined in the Provider Notice Issued 11/09/2018 (illinois.gov). Independent laboratories, pharmacies, and local health departments are required to identify an ORP provider NPI on all claims, whether for Medicaid FFS, or an MCO. The federal ORP requirement was confirmed early in the public health emergency with the Provider Notice Issued 07/08/2020. Other provider types such as physicians, APRNs, ERCs, RHCs, and FQHCs are not required to identify an ORP except if they are billing for consultation services. 

The Medicaid FFS program has claim editing in place to require ORP NPIs in the specified circumstances. MCOs are also expected to require this editing and applicable providers are reminded of their obligation to complete claims accordingly.

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

                                 

 

Kelly Cunningham, Administrator
Division of Medical Programs