Issue Alerts

MO HealthNet OPRA Provider NPI and Enrollment Requirements: Warning Phase Ends November 1, 2019

October 18, 2019

By: Brooke Bennett Aziere and Amanda M. Wilwert

WARNING PHASE ENDS NOVEMBER 1, 2019

On October 17, 2019, MO HealthNet announced the end of its warning phase. Effective for dates of service on or after November 1, 2019, all claims submitted to MO HealthNet are required to include the National Provider Identifier (“NPI”) number of the Ordering, Prescribing, Referring, or Attending (“OPRA”) physician or other professional. In addition, all OPRA practitioners must be individually enrolled as a MO HealthNet provider. MO HealthNet will deny claims missing this information starting on November 1, 2019.

MO HealthNet implemented this policy to comply with state and federal regulations, which provide that state Medicaid agencies must require all claims for payment for items and services that were ordered, prescribed, or referred to contain the NPI of the OPRA practitioner, and that all OPRA practitioners must be enrolled as participating providers in the state Medicaid program. These requirements apply to hospitals, mental health hospitals, state institution long-term care facilities, nursing homes, private home-ICF/IDs, home health agencies, rural health clinics, and hospices.

MO HealthNet has gradually implemented this policy since November 1, 2017, giving impacted providers two (2) years to become compliant. Since October 14, 2018, MO HealthNet has sent providers a warning message on claims that did not contain the OPRA practitioner’s NPI or if the OPRA practitioner was not enrolled with MO HealthNet. The warning message appeared on the providers’ remittance advice and stated, “Attending physician provider/license number missing.” Despite these warnings, providers continue to submit claims without the necessary NPIs and for practitioners who are not enrolled with MO HealthNet. 

Further, for claims that do not require submission of the OPRA practitioner’s NPI, but a provider chooses to submit one anyway, MO HealthNet will deny the claim if the OPRA practitioner is not actively enrolled as a MO HealthNet provider. 

Providers need to act now to make sure all NPIs for ordering, prescribing, referring, or attending practitioners are accurately reported on all claim forms. Additionally, providers must ensure that its practitioners are appropriately enrolled in MO HealthNet before the practitioners order, prescribe, or refer for any service payable under the state Medicaid program. 

For More Information

Foulston's healthcare lawyers maintain a high level of expertise regarding federal and state regulations affecting the healthcare industry. The firm devotes significant resources to ensure our attorneys remain up-to-date on developments. At the same time, our healthcare practice group's relationship with Foulston's other practice groups, including the taxation, general business, labor and employment, and commercial litigation groups, enhances our ability to consider all of the legal ramifications of any situation or strategy. If you have questions regarding MO HealthNet's policy, contact Brooke Bennett Aziere at 316.291.9768 or baziere@foulston.com. For more information on the firm, please visit our website at www.foulston.com.

Established in 1919, Foulston Siefkin is the largest law firm in Kansas. With offices in Wichita, Kansas City, and Topeka, Foulston provides a full range of legal services to clients in the areas of administrative & regulatory; antitrust & trade regulation; appellate law; banking & financial services; business & corporate; construction; creditors’ rights & bankruptcy; e-commerce; education & public entity; elder law; emerging small business; employee benefits & ERISA; employment & labor; energy; environmental; ERISA litigation; estate planning & probate; family business enterprise; franchise & distribution; government investigations & white collar defense; governmental liability; government relations & public policy; healthcare; immigration; insurance regulatory; intellectual property; litigation & disputes; mediation/dispute resolution; mergers & acquisitions; Native American law; oil, gas & minerals; OSHA; privacy & data security; private equity & venture capital; product liability; professional malpractice; real estate; securities & corporate finance; senior housing & care; supply chain management; tax exempt organizations; taxation; trade secret & noncompete litigation; water rights; and wind & solar energy.

This update has been prepared by Foulston Siefkin LLP for informational purposes only. It is not a legal opinion; it does not provide legal advice for any purpose; and it neither creates nor constitutes evidence of an attorney-client relationship.