Ordering, Prescribing, and Referring Claim Identifier Project

Effective July 1, 2022, the Department of Health Care Policy & Financing (the Department) started soft enforcement of the federal requirement 42 CFR § 455.440 that claims for certain types of services contain the National Provider Identifier (NPI) of the provider who ordered the service, and that the NPI is actively enrolled with Health First Colorado.

The OPR claim edits will initially be set to "pay and report" instead of "deny". This will allow providers to analyze their claim Remittance Advice and identify which claims are missing the required OPR NPI number. The Department will continue to monitor claims and keep providers notified of changes.

Providers are required to enter the NPI of the ordering provider into the following locations for claim submission. In the Provider Web Portal, this field may be labeled as "Referring Provider".

Professional claims

  • Paper claims use field 17.b
  • Electronic submissions use loop 2420 with qualifier DK (Ordering), DN (Referring), or DQ (Supervising)

Institutional claims

  • The Attending Provider field (#76) or the Other ID fields (#78 or #79) for both paper and electronic claims
  • Providers should refer to their applicable UB-04 billing manuals for guidance on how each field is used

Contact the Provider Services Call Center for assistance with claim submission.

Beginning July 1, 2022, the Department will begin editing certain categories of claims for compliance with federal Ordering, Prescribing, and Referring (OPR) regulations (42 CFR § 455.440). Services that require an ordering NPI to be both indicated and validated on the claim submission are:

  1. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
  2. Home Health and Private Duty Nursing
  3. Pediatric Personal Care
  4. Radiology and Imaging services
  5. Laboratory services
  6. Physical, Occupational, and Speech Therapy Services (outpatient)
  7. Audiology services
  8. School Health Services Program (physical, occupational, and speech therapy services)
  9. Outpatient Hospital-based therapies, radiology and imaging services, and laboratory services

Additionally, the OPR provider indicated on the claim must be actively enrolled with Health First Colorado (42 CFR § 455.410(b)). If the indicated provider is not actively enrolled the claim will be denied.

It is important for OPR providers to understand the implications of failing to enroll in Health First Colorado. If you are an OPR provider, the other providers who actually render services to Health First Colorado members based on your order, prescription, or referral, will not be reimbursed for such items or services unless you are enrolled. Any claims which do not conform to these requirements may deny, and if they pay in error, they are subject to recoupment.

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Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

All claims for DMEPOS must have the NPI number of the provider who ordered the items to be indicated on the claim. In the Provider Web Portal, this field is labeled "Referring Provider". 

The provider types who may order DMEPOS are physician (05), nurse-midwife (22), osteopath (26), physician assistant (39), and nurse practitioner (41). Reference the DMEPOS billing manual for further details.

Providers are encouraged to use the DME OPR July 2022 Stats document to see what their previous claim submissions have been for OPR completion.

Home Health and Private Duty Nursing

All claims for Home Health and Private Duty Nursing services must have the NPI number of the provider who ordered the items to be indicated on the claim.

The provider types who may order services are physician (05), physician assistant (39), and advanced practice nurse (41). Reference the Home Health billing manual and Private Duty Nursing billing manual for further details.

Pediatric Personal Care

All claims for Pediatric Personal Care services must have the NPI number of the provider who ordered the services to be indicated on the claim.  In the Provider Web Portal, this field is labeled "Referring Provider". 

The provider types who may order Pediatric Personal Care services are physician (05), osteopath (26), and advanced practice nurse (41). Reference the Pediatric Personal Care billing manual for further details.

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Radiology and Imaging Services

All claims for Radiology and Imaging services, including those rendered by non-laboratory providers such as physicians, must have the NPI number of the provider who ordered the items to be indicated on the claim. In the Provider Web Portal, this field is labeled "Referring Provider". 

The provider types who may order these services are: physician (05), physician assistant (39), and advanced practice nurse (41). Reference the Imaging and Radiology billing manual for further details.

Providers are encouraged to use the Radiology and Imaging OPR July 2022 Stats document to see what their previous claim submissions have been for OPR completion.

Laboratory Services

All claims for Laboratory services, including those rendered by non-laboratory providers such as physicians, must have the NPI number of the provider who ordered the items to be indicated on the claim. In the Provider Web Portal, this field is labeled "Referring Provider". 

The provider types who may order these services are: physician (05), physician assistant (39), osteopath (26), certified nurse-midwife (22), and advanced practice nurse (41). Reference the Laboratory Services billing manual for further details.

Providers are encouraged to use the Laboratory OPR July 2022 Stats document to see what their previous claim submissions have been for OPR completion.

Physical, Occupational, and Speech Therapy Services (Outpatient)

All claims for Physical, Occupational, and Speech Therapy Services (outpatient, non-hospital) must have the NPI number of the provider who ordered the items to be indicated on the claim. In the Provider Web Portal, this field is labeled "Referring Provider".

The provider types who may order these services are physician (05), physician assistant (39), and advanced practice nurse (41). Specific instruction exists for services ordered by an Individualized Family Service Plan for Early Intervention. Reference the Physical and Occupational Therapy Billing Manual and Speech Therapy Billing Manual for further details.

Providers are encouraged to use the PTOTST OPR July 2022 Stats document to see what their previous claim submissions have been for OPR completion.

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Audiology

All claims for Audiology services must have the NPI number of the provider who ordered the items to be indicated on the claim. In the Provider Web Portal, this field is labeled "Referring Provider". 

The provider types who may order these services are physician (05), physician assistant (39), and advanced practice nurse (41). Specific instruction exists for services ordered by an Individualized Family Service Plan for Early Intervention. Reference the Audiology Services billing manual for further details.

Providers are encouraged to use the Audiology OPR July 2022 Stats document to see what their previous claims submissions have been for OPR completion.

School Health Services

As of January 1, 2022, all Physical, Occupational, and Speech Therapy Services claims for the School Health Services Program must have the NPI number of the participating school district or Board of Cooperative Educational Services in the ordering provider field.

In the Provider Web Portal, this field is labeled "Referring Provider". Reference the School Health Services Billing Manual for further details.

Outpatient Hospital-based Therapies, Radiology and Imaging Services, and Laboratory Services

All claims for Outpatient Hospital-based therapies, radiology and imaging services, and laboratory services must have the NPI number of the provider who ordered the items to be indicated on the claim.

The provider types who may order services are physician (05), physician assistant (39), and advanced practice nurse (41). Reference the Inpatient/Outpatient Billing Manual for further details.