DHS Guidance for Ordering, Referring and Prescribing

The Department of Human Services has been working in collaboration with Managed Care Organizations (MCOs), county oversight organizations, and RCPA regarding the concerns and challenges with implementing federal Ordering, Referring and Prescribing (ORP) requirements by the January 1, 2018 deadline. The Department of Human Services has informed RCPA of the following:

• The ORP requirements for Fee-for-Service continue to apply; i.e., allORP practitioners must be enrolled in the Pennsylvania Medical Assistance (MA) Program or the rendering provider will not be paid.

• In the HealthChoices managed care delivery system, if a rendering network provider submits a claim to an MCO with the National Provider Identifier (NPI) information that results in edits identifying that the non-networkORP is not enrolled in MA, the claim can be paid. However, if the non-MA enrolled ORP has a high volume of claims, the MCO will work with the network provider and non-MA enrolled ORP to have them enroll in MA or work to transition the member to an enrolled MA provider.

Contact your contracting BH-MCO for additional information.