National Provider Identifier (NPI) requirement on Health Department Clinic claims for enteral formula
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The purpose of this bulletin is to inform Health Department Clinics that the State Medicaid Agency must require all ordering, referring, or prescribing providers (ORP) or other professionals providing services to members enrolled in Virginia Medicaid to be enrolled as participating providers.
Under Medicaid rules, dispensing enteral formula requires an order from a qualified healthcare provider. Furthermore, all claims for services or supplies provided pursuant to a provider order must include the National Provider Identifier (NPI) of the ordering, referring, or prescribing provider on the claim form.
Federal regulations at 42 CFR §§455.410(b) and 455.440 implement the statutory provisions relating to ordering, referring, or prescribing providers found at § 1902(kk)(7)(A) and (B) of the Social Security Act. Under § 455.440, the State Medicaid Agency must require all claims for payment for items and services that were ordered, referred, or prescribed to contain the National Provider Identifier (NPI) of the physician or other professional who ordered or referred such items or services.
Effective 12/01/2023, claims submitted will be denied if the claim does not include the NPI of an enrolled ORP.
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