(Washington, DC) - Section 1902(kk)(7) of the Social Security Act and its implementing regulations at 42. CFR 455.410 provide that every State Medicaid agency must require all ordering and referring physicians or other professionals providing services under the Medicaid State Plan be enrolled as providers.
The Department of Health Care Finance (DHCF) recognizes that in certain situations beneficiaries who are also enrolled in Medicaid may receive orders or referrals for Medicaid health care services from providers who are not enrolled in and do not bill Medicaid for services. Examples include dual eligible beneficiaries who may be receiving primary care services from a Medicare-enrolled provider or beneficiaries who receive services through the Veterans Administration or the military health system (TriCare). To ensure that these beneficiaries do not lose access to services, DHCF is establishing a streamlined enrollment process for providers whose only relationship with the Medicaid program is ordering and/or referring services. To be eligible for the streamlined enrollment process, the provider must:
- Be currently licensed under State law to order or refer the medical services which are the subject of the order or referral;
- Be employed by the Department of Veteran Affairs, the Public Health Service, the Department of Defense/Tricare, the Indian Health Service, a Tribal Organization, a Medicaid-enrolled FQHC or other organization that serves Medicaid beneficiaries but does not submit claims to Medicaid for payment of any service; or be licensed as an intern, resident or fellow in an approved medical residency program.
- Not submit claims to Medicaid for payment of any service; and
- Complete and submit a streamlined enrollment form which includes the provider’s NPI number.
Organizations that are not enrolled Medicaid providers that employ physicians who meet the above criteria may submit a streamlined enrollment form on behalf of their ordering and referring physicians. Such organizations will be required to provide DHCF with the organization’s NPI number.
DHCF’s streamlined enrollment form may be downloaded at www.dc-medicaid.com under Provider→Provider Enrollment→Download Enrollment Package. Completed forms should be returned to:
Department of Health Care Finance
Health Care Operations Administration
Attn: Provider Enrollment and Outreach Branch
One Judiciary Square
441 4th Street, NW
Washington, DC 20001
Claims filed based upon orders or referrals dated on or after March 1, 2014 from non-enrolled providers will be denied.
Questions regarding this policy should be referred to Claudia Schlosberg, Director, Health Care Policy and Research Administration at [email protected] or 202-442-9107.
Questions regarding the enrollment form or claims processing should be referred to: Laurie F. Rowe, Manager, Division of Public and Private Provider Services at either [email protected] or 202-698-2044.