Ordering, Referring, and Prescribing (ORP) Referring Provider Edit Denials for Pharmacies Billing Durable Medical Equipment (DME) and Home Infusion Services Through the Medicaid Management Information System (MMIS)

Ordering, Referring, and Prescribing (ORP) Referring Provider Edit Denials for Pharmacies Billing Durable Medical Equipment (DME) and Home Infusion Services Through the Medicaid Management Information System (MMIS)

The ORP referring provider national provider identifier (NPI) is not required for claims for DME and Home Infusion Services billed by pharmacies through MMIS.

To avoid denials for claims with dates of service on and after August 1, 2025, pharmacy providers should not enter the ORP referring provider’s NPI on the claims for DME and Home Infusion Services billed through MMIS.

Pharmacy providers must include the ORP ordering provider’s NPI on the claim for DME and Home Infusion Services billed through MMIS, and the ordering provider must be actively enrolled with MassHealth as either a fully participating provider or a non-billing authorized ORP provider for the claim to be payable.

Providers should review referring and ordering provider informational edits on their remittance advices and update billing processes to ensure compliance with ORP requirements.

For more information, please refer to All Provider Bulletin 286 (with updated information provided in All Provider Bulletins 361, 376, 380, and 391) at https://www.mass.gov/lists/all-provider-bulletins.

If you have questions regarding this guidance, please contact the LTSS Provider Service Center (844) 368-5184 support@masshealthltss.com.