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Changes to the enforcement of requirements related to Ordering, Referring and Prescribing (ORP) provider enrollment and screening

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Effective Date:

Local Education Agencies (School Divisions) Participating in the Virginia Medical Assistance Program
Karen Kimsey, Director Department of Medical Assistance Services (DMAS)

This bulletin addresses, for Local Education Agencies (LEAs) enrolled with the Department of Medical Assistance Services (DMAS), enforcement of the provider enrollment and screening regulations published by the Centers for Medicare and Medicaid Services (CMS). CMS requires all state Medicaid agencies to implement the provider enrollment and screening provisions of the Affordable Care Act (ACA) (42 CFR 455 Subpart E) for all applicable groups of providers. These regulations were published in the Federal Register, Vol. 76, February 2, 2011, and were effective March 25, 2011.

Ordering, Referring, and Prescribing Providers

The Code of Federal Regulations 42 455.410(b) states that State Medicaid agencies must require all providers that order, refer or prescribe covered services under the State plan for medical assistance, or under a waiver of the plan, to be enrolled as ordering, referring or prescribing (ORP) providers.

The purpose of this rule is to ensure that all orders, prescriptions or referrals for items or services for Medicaid beneficiaries originate from appropriately licensed practitioners who have been screened by the State Medicaid agency and determined to have not been excluded from participating in Medicare or Medicaid.

A DMAS-enrolled ORP provider NPI number must be entered on the DMAS billing claim form for school-based services that require an order or referral under that state’s Medicaid policies. LEA-employed or contracted provider types specified below that refer students for school-based services must obtain a National Provider Identifier (NPI) number and enroll with DMAS as an ORP provider.


Physicians including Psychiatrists

Clinical Psychologists

Professional Counselors

Clinical Social Workers

Psychiatric Clinical Nurse Specialists

Marriage and Family Therapists

School Psychologists-Limited

Nurse Practitioners

School Psychologists

Occupational Therapists

School Social Workers

Physical Therapists

Speech and Language Pathologists with master’s degree

The following LEA provider types may not refer for school-based services and are not required to obtain an NPI number or enroll with DMAS:

  • Registered nurses, licensed practical nurses
  • Personal care assistants
  • School specialized transportation providers
  • Occupational therapy assistants
  • Physical therapy assistants
  • Bachelors level speech-language pathologists
  • Psychological testing technicians

The school may use an NPI of a physician, nurse practitioner or physician’s assistant that is not employed or contracted by the school if that provider has provided a written order for covered services. The NPI Final Rule requires covered health care providers to disclose their NPI numbers to any entities that request them for use in Health Insurance Portability and Accountability Act of 1996 standard transactions. The directory for looking-up NPI numbers is No action is required of providers already enrolled with DMAS as ORP providers.

These requirements for LEA providers will be in effect for claims with dates of service starting July 1, 2021. The ORP provider who’s NPI is reflected on the claim must be enrolled with DMAS at the time the service is rendered.

Consult Chapters II (Provider Participation Requirements) and V (Billing Requirements) of the Local Education Agency Provider Manual for additional information on these requirements. For technical assistance with the registration and enrollment process, providers may contact the provider services helpline at 888-829-5373 or via email at during business hours 8 AM- 5 PM.

Billing Edits

With dates of service starting July 1, 2021 and later, LEA billing claims to DMAS for a school-based service must include an ORP provider NPI number at block 17b on the CMS 1500 paper billing form. If you currently bill through Direct Data Entry (DDE) using the DMAS Web Portal, the ORP NPI number is entered in the “Referring Provider NPI” field. If you bill your claims through Electronic Data Interchange (EDI), the loop/segment is loop 2310A, segment NM109 on the 837P X12 transaction. The NPI number of the ORP provider will ensure the timely processing of the claims.

DMAS has established the following claim edits to ensure compliance with processing requirements for ORP providers.




Resol/Action Effective 07/01/2018



Provider Referral Required



This edit will validate that the ORP's NPI number is enrolled in DMAS.  Refer to the Attachment A for providers required to have referral.


Referring Provider Not on File



This edit will validate the referring NPI number  is valid and actively enrolled in DMAS


Referring Provider Not Eligible on Date of Service



This edit will set if the Referring NPI number is not enrolled and active for t





Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

Medicall (Audio Response System)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

1-800-884-9730 or 1-800-772-9996


Service authorization information for fee-for-service members.


Provider Appeals

DMAS is launching an appeal portal in late May 2021.  You can use this portal to file appeals and track the status of your appeals.  Visit the website listed for appeal resources and to register for the portal.


Managed Care Programs

Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), and Program of All-Inclusive Care for the Elderly (PACE).  In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider.  The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals.

Medallion 4.0

CCC Plus


Magellan Behavioral Health

Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members.

For credentialing and behavioral health service information, visit:, email:,or

Call: 1-800-424-4046


Monday–Friday 8:00 a.m.-5:00 p.m.  For provider use only, have Medicaid Provider ID Number available.



Aetna Better Health of Virginia


Anthem HealthKeepers Plus


Magellan Complete Care of Virginia

 1-800-424-4518 (TTY 711) or 1-800-643-2273

Optima Family Care


United Healthcare


1-844-752-9434, TTY 711

Virginia Premier

1-800-727-7536 (TTY: 711),