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Below are links to the Medicaid alert, the instructions and the forms issued by NYS for enrollment of ordering providers.
We have sent several questions on the forms and their use to the State. Reportedly the State will be issuing further guidance. As soon as we have it we will post it here.
NYS Enrollment Form
The Alert text:
New York State Office of Health Insurance Programs (OHIP)
New York State Education Department
Preschool/School Supportive Health Services Program (SSHSP)
Medicaid in Education Units
Issue #13-07
TO: All SSHSP Medicaid Providers
FROM: NYS OHIP & NYSED
Medicaid in Education Units
DATE: June 24, 2013
SUBJECT: NYS Medicaid Provider Enrollment Requirement for
Providers who Order/Refer School Supportive Health
Services
Medicaid Alert #13-04 issued on April 4, 2013, informed SSHSP billing providers that SSHSP claims for
dates of service on and after May 1, 2013 must contain the NPI of the ordering/referring provider.
Beginning October 1, 2013, in order for billing providers (school districts and counties) to be
reimbursed for SSHSP claims, the ordering/referring provider must also be enrolled as a NYS
Medicaid provider. In this instance, ordering/referring providers include state licensed and currently
registered physicians, physician assistants, nurse practitioners and speech-language pathologists only.
Physical therapists, occupational therapists, registered nurses, licensed psychologists and licensed social
workers are not required to enroll in the NYS Medicaid program for SSHSP purposes.
The Affordable Care Act (ACA) and subsequent federal regulations (42CFR 455.410) include
provisions requiring additional screening of Medicaid providers to improve the integrity of the
Medicaid program and to reduce fraud, waste and abuse. To be in compliance with federal
requirements, ordering/referring providers must be enrolled in state Medicaid programs if they
continue to order or refer services reimbursed by fee-for-service (FFS). Out of state professionals
ordering/referring services that will be billed to fee-for-service Medicaid must be enrolled in the NYS
Medicaid program.
Reporting the NPI of the ordering/referring provider on the Medicaid claim will allow the NYS
Medicaid billing system, eMedNY, to verify the status of the ordering/referring provider’s enrollment
with the NYS Medicaid program. Beginning October 1, 2013, SSHSP billing providers will not be
reimbursed by Medicaid for services that were ordered/referred by non-enrolled NYS Medicaid
providers because of the ACA requirements.
Regarding billing for school supportive health services, school districts and counties should:
Refer to the June 2012 Medicaid Update Article Provider Enrollment Required for Ordering,
Referring and Attending Practitioners and the March 2013 Medicaid Update Article Expedited
Enrollment for Ordering, Prescribing, Referring & Attending Practitioners. In this instance, the
term “attending practitioner” refers to a physician or physician assistant.
Ensure that a provider who orders/refers or will order/refer SSHSP services for a student with an
IEP is enrolled in the NYS Medicaid program.
Ordering/Referring Provider Enrollment Process
The New York State Department of Health is offering a streamlined
ordering/prescribing/referring/attending (OPRA) enrollment process for non-billing providers
(practitioners).
Licensed and currently registered physicians, physician assistants, nurse practitioners and speech-
language pathologists who only order/refer SSHSP services for students with disabilities may utilize the
streamlined OPRA enrollment process at no cost. The streamlined process is solely used to enroll those
providers in the NYS Medicaid program. It will not allow providers to become billing providers (directly
bill Medicaid for their services). The online OPRA form is available at:
https://www.emedny.org/info/ProviderEnrollment/index.aspx.
Medicaid Ordering/Prescribing/Referring/Attending (OPRA) Provider Enrollment Frequently Asked
Questions have been posted on the eMedNY website and can be accessed online at:
https://www.emedny.org/info/ProviderEnrollment/ProviderMaintForms/Core_OPRA_FAQs.pdf
Verification of Ordering/Referring Provider Enrollment
Enhancements have been made to the eMedNY system to provide an online, real-time response for
billing providers to verify the enrollment status of ordering/referring providers. Billing providers can
verify the Medicaid enrollment status of their ordering/referring providers online at:
https://www.emedny.org/info/opra.aspx.
For assistance with the ordering/referring provider enrollment application or with questions about a
provider’s enrollment status, you can contact Computer Sciences Corporation (CSC) directly at
1-800-343-9000 (#3-Clinic, #4-Billing).
If you have any questions or comments regarding this alert, please contact your local Regional
Information Center representative or the NYS Education Department, Medicaid-in-Education Unit at
medined@mail.nysed.gov or the NYS Department of Health at 518-473-2160.
