Medicaid providers and suppliers have likely discovered this the hard way. A provider’s or supplier’s enrollment in the Medicaid program may be insufficient to assure that their provision of a covered and medically necessary good or service to a Medicaid patient will be deemed reimbursable. That is because the Medicaid program will also look at the enrollment status of the provider who Referred, Ordered, Prescribed or Attended (ROPA) the patient referred to the Medicaid provider or supplier. If that ROPA provider is not a Medicaid provider or enrolled as a ROPA provider, the chain of Medicaid eligibility will be broken and that claim from the recipient of the referral will be denied.

Since October 1, 2021, the Medicaid program began rejecting claims submitted by a Medicaid provider but pursuant to a referral, order, prescription or certification from an attending provider who is not enrolled as a Medicaid provider or a ROPA provider. Then-newly issued Federal Medicaid Regulations require the registration of ROPA providers.  ROPA enrollment is, essentially, a partial enrollment. A ROPA provider can refer, order, prescribe or attend patients and the provider, supplier or facility receiving these services can bill Medicaid, but the ROPA provider cannot itself bill for Medicaid services without fully enrolling as a Medicaid provider.

This requirement has led to headaches for many Medicaid providers. Hospitals whose community based staff physicians are called in to attend a Medicaid patient through the emergency room, for example, may have discovered the problem when tests ordered are not reimbursable. Or when that physician sends a Medicaid patient home with a prescription and the patient seeks to fill it at their neighborhood pharmacy, that patient and that pharmacy may discover the medication is not reimbursable. 

So what can Medicaid providers and suppliers do to avoid this problem? First, get the word out. Make sure your referral sources are aware of this issue and their role in causing claim denials for Medicaid patients they’ve treated.  If in Florida, you can refer them to these Florida Agency for Health Care Administration Quick Reference Guides to get them started on the process. Second, check the resources in your state to identify whether your referral sources are either fully enrolled in Medicaid or as a ROPA provider. For example, in Florida, there are three different methods for determining whether your ROPA practitioner is already fully enrolled as a Medicaid provider or a ROPA provider:

1. URPL (Unenrolled ROPA Provider List) – The URPL is a resource available for all Florida Medicaid billing providers. The URPL contains a listing of unenrolled ROPA providers who have been identified on fee-for-service claims. These unenrolled ROPA providers are identified by their NPI. The URPL is updated on a quarterly basis and is available under the Resources section of the ROPA Provider Enrollment page of the public Web Portal.

Please note, providers identified on the URPL have not been validated to qualify for ROPA provider enrollment. Although a ROPA provider’s NPI may be listed on the URPL, the provider must meet the enrollment requirements described in the ROPA Provider Enrollment Overview Quick Reference Guide (QRG).

2. NPI to Medicaid ID Search Engine – Billing providers may verify whether a provider is known to Florida Medicaid by using the search option found on the NPI to Medicaid ID Search Engine. Users will find a link to the search engine under the Resources section of the ROPA Provider Enrollment page. Additionally, users can navigate to the search engine from the homepage, hover over the Provider Services tab, look under the Support column, and select “NPI to Medicaid ID Search Engine.” If a provider is known to Florida Medicaid, entering their NPI in the search engine will identify the provider’s Medicaid ID, enrollment type, and other useful information.

3. Claims Edits – Informational only edits related to compliance with the ROPA requirements began on August 15, 2019. Claims edits will be enforced effective October 1, 2021. The error codes and Explanation of Benefit codes, and Claim Adjustment Reason Code/Remittance Advice Remark Code combinations may be found in the ROPA Claims Changes QRGs. Billing providers may log onto their account on the secure Web Portal to view the PDF of their remittance advices.

For more information, check your state’s Medicaid agency website or follow up with a health care lawyer who has familiarity with your state Medicaid agency.  In Florida, see the Florida Medicaid FAQs with follow up questions.