Date: December 28, 2018
To: All Medical Assistance Program Providers
Re: Ordering, Referring, Prescribing - National Provider Identifier (NPI) Requirements - Delay in Implementation
This informational notice applies to Medicaid fee-for-service claims and not managed care claims.
A November 9, 2018 informational notice informed providers that effective with dates of service on and after January 1, 2019, the Department of Healthcare and Family Services (Department) would require all claims for services that require an ordering or referring practitioner contain the name and National Provider Identifier (NPI) of the practitioner who ordered, referred, or prescribed such services. The requirement also applied to claims where Medicare is the primary payer.
To ensure that this billing requirement is met, and that affected ordering or referring physicians or other professionals (ORP) may get enrolled in the Illinois Medical Assistance Program through the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) system, the Department is delaying implementation of the billing requirement.
Effective with dates of service on and after July 1, 2019 (excluding pharmacy claims, see below), the Department will reject claims if the required ORP information is missing or invalid, or if the ORP is not enrolled with the Department.
Effective with claim receipt dates beginning July 1, 2019, the Department will reject pharmacy claims submitted through the pharmacy point-of-sale system if the prescribing practitioner identified on the pharmacy claim is not enrolled with the Department.
For dates of service prior to July 1, 2019, the Department will send informational messages to providers if the required ORP claim information is missing or invalid, or if the ORP is not enrolled with the Department.
Please refer to the November 9th informational notice for enrollment and specific claim completion requirements. Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.
Teresa T. Hursey