The Department invites you to attend a learning session regarding federal Ordering, Prescribing, and Referring (OPR) regulations and upcoming deadlines for compliance. There will be time for questions and answers. You may sign up for learning sessions or review recordings of past sessions using the following links:
- Ordering, Prescribing, and Referring (OPR) Requirements for Vision Services Stakeholder Engagement
- Speech Therapy Ordering, Prescribing, and Referring (OPR) Stakeholder Engagement
- Physical and Occupational Therapy Ordering, Prescribing, and Referring (OPR) Stakeholder Engagement
- Audiology Ordering, Prescribing, and Referring (OPR) Stakeholder Engagement
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:
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
- Home Health and Private Duty Nursing
- Pediatric Personal Care
- Radiology and Imaging services
- Laboratory services
- Physical, Occupational, and Speech Therapy Services (outpatient)
- Audiology services
- School Health Services Program (physical, occupational, and speech therapy services)
- 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.
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, 65), podiatrist (06) for items within their scope of ordering authority, nurse-midwife (22), osteopath (26), physician assistant (39), and nurse practitioner (41). Reference the DMEPOS billing manual for further details.
If a physician renders a service under their own ordering authority, that rendering physician’s NPI number should be placed in the applicable OPR field on the claim.
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, 65), podiatrist (06), osteopath (26), 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, 65), podiatrist (06), osteopath (26), physician assistant (39), and advanced practice nurse (41). Reference the Pediatric Personal Care billing manual for further details.
Providers are encouraged to use the Pediatric Personal Care OPR March 2024 Stats document to see what their previous claims submissions have been for OPR completion.
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, 65), podiatrist (06), optometrist (07), certified nurse-midwife (22), osteopath (26), physician assistant (39), certified registered nurse anesthetist (40), and advanced practice nurse (41). Reference the Imaging and Radiology billing manual for further details.
If a physician renders a service under their own ordering authority, that rendering physician’s NPI number should be placed in the applicable OPR field on the claim.
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, 65), podiatrist (06), optometrist (07), osteopath (26), certified nurse-midwife (22), physician assistant (39), certified registered nurse anesthetist (40), advanced practice nurse (41), and pharmacist (75). Reference the Laboratory Services billing manual for further details.
If a physician renders a service under their own ordering authority, that rendering physician’s NPI number should be placed in the applicable OPR field on the claim.
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, 65), podiatrist (06), 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.
If a physician renders a service under their own ordering authority, that rendering physician’s NPI number should be placed in the applicable OPR field on the claim.
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, 65), 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.
If a physician renders a service under their own ordering authority, that rendering physician’s NPI number should be placed in the applicable OPR field on the claim.
Providers are encouraged to use the Audiology OPR March 2024 Stats document to see what their previous claims submissions have been for OPR completion.
School Health Services
As of July 1, 2024, all Physical, Occupational, and Speech Therapy Services claims for the School Health Services Program must have the NPI number of the individual provider in the ordering, prescribing, and referring provider (OPR) 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, 65), podiatrist (06), certified nurse-midwife (22), osteopath (26), physician assistant (39), and advanced practice nurse (41). For laboratory and radiology and imaging services specifically, the following provider types may also order services: optometrist (07) and certified registered nurse anesthetist (40). Reference the Inpatient/Outpatient Billing Manual for further details.
If a physician renders a service under their own ordering authority, that rendering physician’s NPI number should be placed in the applicable OPR field on the claim.
Vision Care and Eyewear Services
All claims for Vision Care and Eyewear 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, 65), optometrist, (07), and osteopath (26). Reference the Vision Care and Eyewear billing manual for further details.
If a physician, optometrist, or osteopath renders a service under their own ordering authority, that rendering physician’s NPI number should be placed in the applicable OPR field on the claim.
Providers are encouraged to use the Vision Care October 2024 Stats document to see what their previous claims submissions have been for OPR completion.
The Department invites providers to attend a learning session regarding federal Ordering, Prescribing, and Referring (OPR) regulations for vision services and upcoming deadlines for compliance. There will be time for questions and answers.
Wednesday, October 30, 2024, 10:00 AM -11:00 AM MT
View meeting materials and recording
Monday, November 18, 12:00-1:00 PM
Sign up for the 11/18/24 session or view meeting materials and recording
Thursday, January 16, 4:00-5:00 PM
Sign up for the 1/16/25 session or view meeting materials and recording
Doula Services
All claims for Doula services must have the NPI number of the provider who ordered/referred the items to be indicated on the claim. In the Provider Web Portal, this field is labeled "Referring Provider".
The enrolled provider types who may order/refer these services are: Physicians (PT 05, 65), Physician Assistants (PT 39), Advanced Practice Nurses (PT 41), Nurse Midwife (PT 22), Certified Professional Midwives/Direct Entry Midwife (PT 69), Licensed Psychologist (PT 37), and Licensed Behavioral Health Clinician (PT 38).
Reference the Doula Services billing manual for further details.
Lactation Support Services
All claims for Lactation Support Services must have the NPI number of the provider who ordered/referred the items to be indicated on the claim. In the Provider Web Portal, this field is labeled "Referring Provider".
The enrolled provider types who may order/refer these services are: Physicians (PT 05, 26, 65), Nurse Midwife (PT 22), Physician Assistants (PT 39), and Advanced Practice Nurses (PT 41).
Reference the Lactation Support Services Billing Manual for further details.