Comment on OHCA ordering and referring provider issue

Posted on: 9/14/16

The Oklahoma Health Care Authority (OHCA) is inviting comments on its problematic Provider Letter 2016-25. But act fast – the deadline for comments is this Thursday, Sept. 15.  

Provider Letter 2016-25 specifies that “all claims for reimbursement for items and/or services that were ordered or referred contain the National Provider Identifier (NPI) of the physician or other professional who ordered, referred, and/or provided such items or services.”  If the ordering or referring provider is not contracted with OHCA, the claim will be denied.

A federal rule now requires states to screen for the Medicaid participation of ordering and referring providers, but does not specify which services are considered “referred.” OHCA started with a narrow definition of the referred services to which it applies this test, but is now applying the requirement to all referring providers shown on claims. Hospitals report the denial of claims for emergency hospital services, rendered by contracting SoonerCare physicians, for patients referred to the hospital ED by non-contracting providers, or evaluated by a non-contracting, on-call specialist.

OHCA Provider letter 2013-44 (Oct. 29, 2013), listed a few specific types of billing provider to which this ordering/referring limitation would apply, such as home health, laboratory, and radiology.

Provider letter 2014-63 (Dec. 30, 2014), added the ordering/referring provider requirement to a few more billing provider types and specialties, including nutritionists, audiologists, and sleep study centers.

Provider letter 2016-25 (Aug. 16, 2016), applies the requirement to “all claims for reimbursement of items and/or services that were ordered or referred…” (emphasis added).

Comments on Provider letter 2016-25 should be submitted by close of business, Sept. 15, 2016, via the comment box(Rick Snyder)

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