Attending, Rendering, Ordering, Prescribing or Referring Providers – Update

Beginning with date of service Feb. 1, 2016, the presence of the National Provider Identifier (NPI) of a non-enrolled ordering, prescribing or referring provider on a N.C. Medicaid or N.C. Health Choice (NCHC) has resulted in a “pay and report edit” appearing on the Remittance Advice (RA). N.C. Division of Medical Assistance (DMA) will implement this requirement in phases before claims suspend. During a period of time, billing providers will receive an EOB warning message on their RA when the attending, rendering, ordering, prescribing or referring provider’s NPI submitted on the billing provider’s claim indicates that provider is not enrolled in the NC Medicaid or NCHC program. DMA will notify providers when the edit disposition will change from a “pay and report” status to “suspend” status. When the edit is changed to suspend claims, if an attending, rendering, ordering, prescribing or referring provider does not enroll within the 90-day timeframe, the billing provider will receive a denial with an EOB stating that “the attending, rendering, ordering, prescribing or referring provider is not enrolled.” This will permit the billing provider to notify the attending, rendering, ordering, prescribing or referring provider to begin the enrollment process on NCTracks. This is targeted for an August 1, 2016 implementation.

Source: https://ncdma.s3.amazonaws.com/s3fs-public/documents/files/Special Bulletin_OPR_2016_05.pdf