HFS Delays Medicaid Ordering/Referring/Prescribing NPI Requirement

June 25, 2019


The Illinois Dept. of Healthcare and Family Services (HFS) has informed IHA that it will delay until October 1, 2019 implementation of the ordering, referring, prescribing (ORP) requirement.  Under federal law, all Medicaid claims for services requiring an order or referral must include the name and National Provider Identifier (NPI) of the clinician who ordered, referred, or prescribed the services. The ORP requirement applies to claims billed to traditional Medicaid, including Medicare crossover claims, and to the Medicaid Managed Care Organizations (MCOs).

Implementation was initially scheduled for January 1, 2019, but later delayed until July 1, 2019, and now October 1, 2019, in response to operational questions raised by IHA and others, including how hospitals could verify an ORP’s enrollment in Illinois Medicaid (see HFS Provider Notice, December 28, 2018).  This delay applies to claims submitted by all Medical Assistance providers, including enrolled pharmacies.  HFS understands that access to this enrollment information is critical to comply with the new requirement and is currently working to give hospitals and other providers the ability to verify whether an ORP is actively enrolled in Illinois Medicaid.  HFS expects to have this tool available prior to the October 1, 2019 implementation date.

All authorized prescribing practitioners, including residents, fellows, physicians, advanced practice nurses, and physician assistants, must be enrolled in Illinois Medicaid before October 1, 2019.  

Contact us with any questions.