Lengthy checklists representing the time-consuming process of provider screening are shown along with the question: How do CMS provider screening requirements affect out-of-state Medicaid claims?

CMS Provider Screening Requirements & Out-of-State Medicaid Claims

| No Comments

EligibilityAdvocates Blog

CMS Provider Screening Requirements & Out-of-State Medicaid Claims

Posted on January 21, 2021

Lengthy checklists representing the time-consuming process of provider screening are shown along with the question: How do CMS provider screening requirements affect out-of-state Medicaid claims?

EligibilityAdvocates specializes in all regulations that affect out-of-state Medicaid reimbursement, including CMS provider screening requirements and state-specific procedures.

The New Year is here and it’s time for families to start traveling. With travel, come patients from out-of-state. With out-of-state patients, come out-of-state Medicaid claims.

All states have their own rules and regulations regarding Medicaid. But on March 25, 2011 the Centers for Medicare & Medicaid Services (CMS) implemented additional screening requirements for states to follow for Medicaid provider enrollment. If these requirements are not met, the provider risks termination from the Medicaid program and/or a delay in reimbursements.

How Do CMS Provider Screening Requirements Affect Out-of-State Medicaid Claims?

Here are the top 6 requirements, which can be found in the Federal Register, that affect the out-of-state Medicaid enrollment and billing process:

1.) Database Checks

Requirement: States are required to screen all providers “upon initial enrollment and monthly thereafter for as long as the provider is enrolled in the Medicaid program” (p. 5897).


2.) Unscheduled & Unannounced Site Visits

Requirement: The Secretary may carry out unscheduled and unannounced site visits. “States must conduct pre-enrollment and post-enrollment site visits for those categories of providers the State designates as being in the “moderate” or “high” level of screening.” Providers must permit the on-site visits (p. 5898-5899).


3.) Provider Enrollment & Provider Termination

Requirement: All providers must undergo screening at least once every 5 years. States are required to deny or terminate the enrollment of providers if:

  1. The provider “does not submit timely and accurate disclosure information or fails to cooperate with all required screening.”
  2. The provider is “terminated on or after January 1, 2011 by Medicare or any other Medicaid program or CHIP.”
  3. The “provider fails to submit sets of fingerprints within 30 days of a State agency or CMS request.”

States can also deny enrollment to a provider “if the provider has falsified any information on an application or if CMS or the State cannot verify the identity of the applicant” (p. 5900).


4.) Criminal Background Checks & Fingerprinting

Requirement: Each provider the State designates as within the “high” level of screening is subject to fingerprinting (p. 5901).


5.) Deactivation & Reactivation of Provider Enrollment

Requirement: Medicaid providers who have “not submitted any claims or made a referral that resulted in a Medicaid claim for a period of 12 consecutive months” must have their Medicaid provider enrollment deactivated (p. 5903).


6.) Enrollment & NPI of Ordering or Referring Providers

Requirement: The State “must require all ordering or referring physicians or other professionals to be enrolled under a Medicaid State plan or waiver of the plan as a participating provider.” Their NPI must be on applications to enroll and on all claims for payment (p. 5903).


The CMS regulations established more consistency in the screening process so that states can better ensure providers are qualified to serve the Medicaid population. However, since the CMS provider screening requirements were enacted, many providers have been discouraged to seek out-of-state Medicaid reimbursement because of the amount of work involved in the application process. Plus, on top of these standardized enrollment requirements, states vary in their rules and regulations for filing claims.

Don’t Miss Out on Out-of-State Medicaid Revenue


At EligibilityAdvocates, we are experts in out-of-state Medicaid. From CMS provider screening requirements to each state’s individual Medicaid program (and temporary waivers related to COVID-19), we keep track of all rules and regulations that affect out-of-state Medicaid reimbursement.

When you outsource out-of-state Medicaid work to EligibilityAdvocates, you can collect payment for these complex claims without devoting your time and resources to monitoring (ever-changing) federal and state regulations. We will do so for you and take care of every aspect of Medicaid enrollment for both the provider and facility, claims submission, and claims follow-up.

Contact us today to learn more about how we can help your practitioners and facility meet CMS provider screening requirements and obtain reimbursement for your out-of-state Medicaid claims – all at a performance-based rate.


By EligibilityAdvocates

A doctor completes a form on a tablet below the caption - FREQUENTLY ASKED QUESTIONS: OPR Provider Enrollment

Ordering, Prescribing, and Referring (OPR) Provider Enrollment FAQs

| No Comments

EligibilityAdvocates Blog

Ordering, Prescribing, and Referring (OPR) Provider Enrollment FAQs

Posted on January 21, 2021

Even if you do not submit claims to Medicaid, you are required to complete OPR provider enrollment if you are an ordering, prescribing, and referring (OPR) provider for Medicaid patients. This requirement was implemented by the Affordable Care Act (ACA) and the Centers for Medicare & Medicaid Services (CMS).

To help you navigate this process, we’ve compiled a list of the most common questions we receive from ordering, prescribing, and referring providers regarding Medicaid enrollment.

A doctor completes a form on a tablet below the caption - FREQUENTLY ASKED QUESTIONS: OPR Provider Enrollment

EligibilityAdvocates can answer your OPR provider enrollment questions and manage the Medicaid enrollment process for you.

OPR Provider Enrollment FAQs


1) Why are OPR providers required to complete Medicaid enrollment?

Additional integrity requirements are placed on state Medicaid programs. This requirement complies with federal regulation 42 CFR 455.410 concerning the screening and enrollment of providers.


2) How do I know if I should enroll as an OPR provider?

This type of enrollment may be suitable for you if:

  • You occasionally see Medicaid recipients who need additional services/supplies that can be covered by Medicaid.
  • You do not plan to submit claims to Medicaid for reimbursement.
  • You are not enrolled as another Medicaid provider type.

3) What are the OPR requirements?

The 3 basic OPR requirements are:

  1. The provider who wrote the order/prescription/referral must be enrolled in Medicaid (either as a participating Medicaid provider or as an OPR provider) and that provider’s NPI must be included on the claim.
  2. The provider’s NPI must be for an individual physician or non-physician practitioner (not an organizational NPI).
  3. The provider must be of a specialty type that is eligible to order, prescribe, or refer.

4) Do I have to be enrolled as a participating provider or can I be enrolled only as an OPR provider?

If you will only be ordering, prescribing, and referring services for Medicaid recipients and won’t be billing Medicaid for these services, you may enroll as only an OPR provider. But if you wish to bill Medicaid, you must enroll as a fully participating Medicaid provider.

OPR providers do not bill Medicaid and are not required to treat Medicaid patients.


5) If I am already enrolled as an active provider with a state’s Medicaid program, do I also need to enroll as an OPR provider in that state?

No; anyone who is an active Medicaid participating provider does not need to enroll again as an OPR provider.


6) Is there a separate Medicaid enrollment application for OPR providers?

Yes; each state has a separate Medicaid enrollment application specifically for OPR provider enrollment.


7) If I am enrolled in one state’s Medicaid program, do I still need to enroll in other states’ programs?

If you order, prescribe, refer, or render services for a Medicaid patient, you must be enrolled in the state program to which the patient belongs. For example, if you are a provider located in California and enrolled in California’s Medicaid program and you write a prescription for an Arizona Medicaid recipient, you must be enrolled in the Arizona Medicaid program as well.


8) What will happen if I fail to complete Medicaid enrollment as an OPR provider?

The healthcare providers and facilities who deliver services according to your orders/prescriptions/referrals will not be reimbursed by Medicaid for those services if you are not enrolled and your NPI is not included on the Medicaid claims they submit.


9) If a claim is denied because the OPR provider is not enrolled in the Medicaid program, can the OPR provider retroactively enroll?

In most cases the billing provider can resubmit the claim after the OPR provider enrolls. There are state-specific claim timely filing limitations.


10) Do claims submitted to Managed Care Organizations (MCOs) have to follow the OPR requirements?

This depends on each MCO or HMO and its specific requirements.

OPR Provider Enrollment Services


EligibilityAdvocates handles all aspects of Medicaid enrollment for both OPR providers and fully participating Medicaid providers, including out-of-state Medicaid enrollment.

If you have more questions regarding OPR provider enrollment or would like EligibilityAdvocates to take care of this process for you, please contact us here.


By EligibilityAdvocates

A map of the United States illustrates the 50+ Medicaid programs that we will monitor for you when you outsource out-of-state Medicaid work to EligibilityAdvocates.

Why Outsource Out-of-State Medicaid Billing? 

| No Comments

EligibilityAdvocates Blog

Why Outsource Out-of-State Medicaid Billing?

Posted on January 8, 2021

If you’re struggling with out-of-state Medicaid enrollment and/or billing in-house, it may be time to consider an alternative solution. Outsource out-of-state Medicaid enrollment and billing to a performance-based company that specializes in these claims.

Here are the top reasons to outsource out-of-state Medicaid enrollment and billing:


1. Lack of internal resources.

Like many healthcare organizations, you may choose to write off out-of-state Medicaid accounts rather than allotting time and resources to working these complex claims. However, you are missing out on a substantial form of reimbursement that could improve your revenue cycle while reducing aged receivables.

2. Lack of expertise in complicated out-of-state Medicaid claims requirements.

If you have tried to manage these difficult claims internally, you’ve probably found that they require more time and expertise than your staff can reasonably deliver. EligibilityAdvocates specializes in out-of-state Medicaid and we handle all the work necessary for reimbursement. This includes enrolling providers and facilities in states’ Medicaid programs, billing and submitting claims, following up on any delayed claims, and appealing denials. We devote our time and extensive resources to all aspects of the out-of-state Medicaid process so your teams can focus on other objectives.

3. No standardization – there are over 50 Medicaid programs.

A map of the United States illustrates the 50+ Medicaid programs that we will monitor for you when you outsource out-of-state Medicaid work to EligibilityAdvocates.

EligibilityAdvocates is knowledgeable in all 50+ Medicaid programs.

Each state, U.S. territory, and Washington, D.C. has its own Medicaid program with different and continually changing rules. Additionally, there are new and temporary Medicaid flexibilities to navigate due to COVID-19 and these vary by state as well. When you choose a partner who is proficient in every Medicaid program, you don’t have to keep track of all these moving parts – we do it for you.

4. Occurrence is increasing, Medicaid Expansion, and Americans love to travel.

Even in light of COVID-19, a recent survey of over 30,000 Americans found that 46% are ready to travel once lockdowns are lifted. Expansion and the increase of Medicaid patients accessing care outside their enrollment states will continue to grow for hospitals in the future.

5. Return on investment – move to performance-based contingent fee pricing.

It’s difficult to realize a positive ROI when a facility manages, enrolls, and/or bills out-of-state accounts. Switch to a performance-based resource. There are no up-front costs OR facility enrollment fees when you outsource out-of-state Medicaid work to EligibilityAdvocates. You only pay for our services once we’ve delivered results and the hospital has received payment.

6. Improve A/R and see an increased remittance.

Our out-of-state Medicaid specialists have the knowledge, experience, and technology to provide you with quicker reimbursement, at a higher rate. EligibilityAdvocates combines out-of-state Medicaid experts with workflow automation technology to streamline claims resolution management.

7. Look to EligibilityAdvocates to expand your revenue cycle team with no increase in internal labor costs.

EligibilityAdvocates is a performance-based partner that serves as an extension to your revenue cycle team. By partnering with us, you can ensure your out-of-state Medicaid accounts are settled without the need to hire additional staff to work them. You won’t have to train new employees, add them to your payroll or benefits programs, or pay for any extra office space and equipment (desks, computers, phones, etc.). These are fixed expenses, regardless of how much money your staff actually collects. Conversely, when you hire EligibilityAdvocates you’ll only pay us as much as our performance warrants.

Outsource Out-of-State Medicaid Billing


You may not have the time and resources needed to work out-of-state Medicaid claims, but you can’t afford to lose out on this valuable source of revenue either. The simple solution is to outsource out-of-state Medicaid work to an external billing company like EligibilityAdvocates.

Protect your revenue without the hassle – outsource out-of-state Medicaid billing to EligibilityAdvocates today.


By EligibilityAdvocates