NY – OPR Providers Must Revalidate for Claims to Be Paid

March 2017 ~

Federal regulation requires State Medicaid agencies to revalidate the enrollment of all providers every five years and ordering/prescribing/referring (OPR) providers who do not comply with this revalidation requirement will be terminated from the Medicaid Program.

Due to the number of providers Medicaid payment is contingent on the ordering/prescribing/referring (OPR) provider also revalidating their enrollment in Medicaid, the New York State (NYS) Department of Health has determined that many providers are at risk for not being paid for their services if the OPR provider has not complied with the revalidation requirement.

The Claim Adjustment Reason Code for non-enrolled OPR provider on 835 remittance will appear as: B7 – This Provider was Not Certified/Eligible to be Paid For this Procedure/Service on this Date of Service.

To avoid potential non-payable claims, Medicaid New York suggests OPR providers revalidate their enrollment using the required revalidation form and instructions are available on the eMedNY revalidation page and urges physicians and billing/rendering providers to confirm that their OPR providers are enrolled before rendering service via the enrolled practitioners search.

Source(s): Medicaid New York;