As described in All Provider Bulletin 286 (with updated information provided in All Provider Bulletins 361, 376, 380, and 391), claims submitted to MassHealth for services that require an order, referral or prescription must include the national provider identifier (NPI) of an authorized ordering, referring or prescribing (ORP) provider. The ORP provider must also be enrolled with MassHealth for the claim to be payable.
Enter the ORP provider’s NPI in the Referring Provider field/segment if the claim:
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- is for a service that requires a Primary Care Clinician (PCC) or Primary Care Accountable Care Organization (PCACO) referral; or
- is for a laboratory service or a diagnostic testing service; or
- is submitted on an 837I or UB-04 (such claims only have a Referring Provider field).
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Please note that an ORP provider’s NPI is only required on an 837I or UB-04 when the ORP provider is different than the Attending Provider. Enter the ORP provider’s NPI in the Ordering Provider field for all other impacted claims.
All Provider Bulletin 286 (and all of the referenced Bulletins) can be found on Mass.gov at: https://www.mass.gov/lists/all-provider-bulletins.
If you have questions, please contact MassHealth at (800) 841-2900 or provider@masshealthquestions.com.