Non-Billing, Ordering, Prescribing, and Referring (NOPR) Enrollment Guidance for Institutional Providers

Non-Billing, Ordering, Prescribing, and Referring (NOPR) Enrollment Guidance for Institutional Providers

There have been questions about whether institutional providers need to enroll their practitioners as NOPRs. This guidance applies to all providers who do not enroll rendering providers, but primarily affects Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Services (IHS).

Billing providers must include the National Provider Identifier (NPI) of an enrolled MaineCare practitioner who is ordering, prescribing, or referring on their claims to receive reimbursement for the service. These practitioners are known as NOPRs and must enroll in MaineCare independently or as part of an organization.

This requirement is for all prescription claims (including Point of Sale claims) as well as claims for the following:

• Clinical laboratories for ordered tests
• Imaging centers for ordered imaging procedures
• Supplies of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

If your organization has practitioners who do not bill MaineCare but do order, prescribe, or refer, you must enroll these practitioners as NOPRs under your enrollment to ensure continuity of claims payments, authorizations, referrals, and prescriptions that they issue. This can be completed utilizing the maintenance case functionality on the Health PAS Online Portal. Please note that NOPR providers who are not enrolled with MaineCare may not prescribe, order, and refer services for MaineCare members.

We are in the process of completing our first round of provider revalidation. After it is completed, claim edits will deny claims when the ordering, prescribing, or referring provider is not enrolled as a full MaineCare provider or as a NOPR. We will notify you before we start denying claims.

Generally, if practitioners that provide services in your facilities are already enrolled with MaineCare, either as a full MaineCare provider or a NOPR with another MaineCare provider, you do not need to enroll them as NOPRs under your provider enrollment. Claims for services that your practitioners prescribe or authorize will be processed for payment in MIHMS. However, if these practitioners discontinue their other enrollment(s) with MaineCare, the claims will deny unless you affiliate that practitioner with your organization by enrolling them as a NOPR under your provider enrollment.  

Please contact your Provider Relations Specialist if you have any questions.  

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Reminder for Providers Billing on UB-04 and 837I Claims 

Providers who bill on UB-04 or 837I claims must include an Attending Physician Name, including secondary identifiers, when submitting your claim in MIHMS. Form Locator 76 is a required field and will be used to validate that your attending physician is enrolled with MaineCare. The attending provider is the individual who has overall responsibility for the patient’s medical care and treatment. There are a few, very limited services that do not require a National Provider Identifier (NPI) in the Attending Provider field. 

Services that do not require an NPI in the Attending Provider field: 

1. Emergency ambulance trips

• Emergency transportation services when they are the only services on the claim: Service codes identified – A0021, A0225, A0420, A0424, A0425, A0427, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0998, and A0999 (to also include A0428 when billed with modifier QL)  
• Revenue code 0540

2. Singular or roster billing of Influenza or Pneumococcal Vaccinations and their administrations when these are billed as the only services on the claims. Administration codes are:

• Influenza G0008
• Pneumococcal G0009
• If all UB-04/837I billers are using the above admin codes, Revenue Code 0771

3. Vaccines 

• Influenza 90655, 90656, 90657, 90658, 90660, 90673, 90685, 90686, 90688
• Pneumococcal 90670
• Revenue Code 0636

Type 1 vs. Type 2 NPI 

Most providers are required use a Type 1 NPI. The only exceptions are Private Non-Medical Institutions (PNMIs) or a self-referred screening mammography. 

For PNMIs, once you have completed the full enrollment revalidation process, you will be required to use a Type 1 NPI. Until that time, you can continue using a Type 2 NPI. 

When screening mammography services are self-referred and as a result an attending physician NPI is not available, use the facility Type 2 NPI in the attending physician identifier field on the claim. For the self-referred mammography screenings, Type 2 NPIs are allowed.   

• 77057, Screening mammography, bilateral (2-view film study of each breast)
• G0202, Screening mammography, producing direct digital image, bilateral, all views
• 77063, Screening digital breast tomosynthesis, bilateral (List separately in addition to the code for primary procedure)
• 77052, CAD screening mammography

In addition to including the attending physician’s NPI, you must also include a secondary identifier qualifier, as listed below. 

UB-04: Secondary Identifier Qualifiers

• 0B - State License Number
• 1G - Provider UPIN Number
• G2 - Provider Commercial Number 

837I: Secondary Identifier Qualifier

This is based on the provider’s NPI or Atypical Provider Identifier (API) number(s). If the provider enrolled with an NPI, then use “EI” and the NPI number as in the example below. 

NPI Example:

NM1*71*1*LastName*FirstName****XX*9999999999~

REF*EI*111111111~ 

If the provider enrolled with an API then use “1D” and the Employer Identification Number (EIN) number as in the example below. 

API Example:

NM1*71*1*LastName*FirstName****24*111111111~

REF*1D*A#########~ 

 Health PAS Online Portal 

When entering claims in the portal, you will enter the NPI only in the attending provider field. Do not enter the provider’s name as the portal will not translate that information to MIHMS at this time. 

Please call Provider Services with questions at: 1-866-690-5585.