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MassHealth Ordering, Referring, and Prescribing Policy

There are some significant changes taking effective September 1, 2016 with the Massachusetts Medicaid program (MassHealth).  Every provider licensed in the state must now have an active enrollment record with MassHealth at least as an ordering and referring provider. Healthcare providers may not renew their medical license without an active ordering and referring provider enrollment record on file with MassHealth.

Changes include:

  • Various individual providers must now partic¡pate in the MassHealth program as either a billing or nonbilling provider if they are physician credentialingordering, referring, or prescribing (ORP) to MassHealth patients;
  • MassHealth will no longer pay the billing provider for services without the NPI of the ORP provider;
  • Individual providers will not be allowed to obtain a new license or renew their state license unless they are participating in MassHealth at least as a non-billing ORP provider;
  • Individual providers may not be included on a private insurance participating provider network unless they are signed up as a billing or non-billing MassHealth ORP provider;

Also, effective September 1, 2016, group practices that employ a physician assistant, certified registered nurse anesthetist, or nurse mid-wife can no longer bill services incident to the supervising physician’s NPI, but must bill under their own NPI and be paid at the applicable fee schedule rate (currently 85% of the fee schedule).

These changes have a dramatic impact on many providers in the state.  Providers who need to enroll as a nonbilling provider for ordering and referring purposes can obtain enrollment information at http://www.mass.gov/eohhs/provider/insurance/masshealth/aca/aca-section-6401enrollment-information.html.