The January 2 Maryland Medical Assistance Program General Provider Update includes a notice that Federal regulations require Medicaid to enroll all Ordering, Referring and Prescribing (ORP) practitioners as participating providers in order for Medicaid to reimburse for their ordered, referred, and prescribed services (42 CFR § 455.410). To comply with this requirement, Maryland Medicaid must deny any Fee-For-Service (FFS) pharmacy claim where the prescriber is not actively enrolled in Maryland Medicaid.
Implementation in 2024 will be-phased as follows:
- As of January 3, Maryland Medicaid is denying pharmacy claims for non-behavioral health drug classes if the prescriber is not enrolled.
- Effective July 1, 2024, Maryland Medicaid will deny all pharmacy claims regardless of drug class if the prescriber is not enrolled.
All practitioners–including medical trainees, interns, and unlicensed residents–who prescribe to Maryland Medicaid participants must be actively enrolled Medicaid providers for their prescriptions to be covered at the point-of-sale. A licensed practitioner may enroll as either a fully participating (billing or rendering) provider, or an ORP-only Provider (does not bill for services or sign a full Provider Agreement). Unlicensed medical trainees must enroll as ORP only providers.
It is critical that practitioners who prescribe to Medicaid participants enroll ASAP to ensure that patients can receive Medicaid covered medications. Prescriber enrollment status can be checked via the Provider Verification System. Updates and resources are available on MDH’s Ordering, Referring, and Prescribing (ORP) Providers webpage.