Medicaid ORP Requirement Delayed to January 1, 2020

October 30, 2019


Medicaid ORP Requirement Delayed to January 1, 2020

The Illinois Department of Healthcare and Family Services (HFS) has informed IHA that implementation of the Ordering/Referring/Prescribing (ORP) requirement has been delayed to January 1, 2020. IHA does not anticipate HFS will grant any further delays.

As IHA has previously communicated, HFS plans to implement claims processing edits that will require all Medicaid claims for services that require an order or referral to include the name and National Provider Identifier (NPI) of the clinician who ordered, referred, or prescribed the services, as required under federal law. The ORP requirements apply to claims billed to traditional Medicaid, including Medicare crossover claims, and to the Medicaid Managed Care Organizations (MCOs).

Although initially scheduled for implementation on January 1, 2019, HFS has delayed activation of the edits a few times over the past year to secure answers to operational questions raised by IHA’s Committee on Patient Financial Services and other providers, including how hospitals may verify a provider’s enrollment in Illinois Medicaid and how the MCOs will apply the ORP edits.

HFS understands that access to enrollment information is critical to compliance and launched a tool in early October that allows providers to verify a clinician’s enrollment in Illinois Medicaid. The Illinois Medicaid Provider Directory may be accessed on the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) system home page. The Illinois Association of Medicaid Health Plans (IAMHP) is also working on adding a new ORP section to the Comprehensive Billing Manual for MCO claims.