Ordering/Referring/Prescribing Only Enrollment Information
This enrollment type is for those physicians or non-physician practitioners who do
not send claims directly to Medi-Cal for services provided, but must enroll in the Medi-Cal program if they order, refer or prescribe items or services for Medi-Cal beneficiaries.
Federal Medicaid Regulations 42 Code of Federal Regulations (CFR) Section 455.410(b), mandates that the “State Medicaid agency must require all ordering or referring physician or other professionals providing services under the State Plan or waiver of the plan to be enrolled as participating providers.” In addition, the State of California has enacted laws that conform to the new federal regulations. Welfare and Institutions (W&I) Code, Section 14043.1(b) & (o), effective January 1, 2013, now require the enrollment of ordering, referring and prescribing providers in the Medi-Cal Program.
Pursuant to the regulatory Provider Bulletin published in January 2013, DHCS has established procedures for the enrollment of physicians and non-physician practitioners who are required to enroll in the Medi-Cal program for the sole purpose or ordering, referring or prescribing items or services to Medi-Cal beneficiaries.
Please note that this type of enrollment does
not allow the Medi-Cal program to reimburse the ordering, referring or prescribing provider for services provided directly to Medi-Cal beneficiaries. To determine whether or not you qualify, please read the detailed regulatory Provider Bulletin “Medi-Cal Requirement for Ordering/Referring/Prescribing Providers Forms and Procedures.”
Qualifications to enroll as an Ordering/Referring/Prescribing Provider
There are three basic requirements for ordering, referring or prescribing for Medi-Cal beneficiaries:
The physician or non-physician practitioner must be enrolled in Medicare or the Medi-Cal program.
The ordering, referring or prescribing provider must obtain and submit their Individual (Type 1) NPI. An Organizational (Type 2) NPI is not acceptable.
The physician or non-physician practitioner must be of the specialty type eligible to order, refer and prescribe in accordance with State law and the physician or non-physician practitioner’s Practice Act.
Be sure to gather the required documents listed below, as applicable, in order to upload them into PAVE as you complete your PAVE application. Please ensure the following uploaded documents are legible.
Current California Professional License of applicant or provider (pocket license).
Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider who is signing the form. The signature must be that of the physician or non-physician applicant.
National Plan and Provider Enumeration System (NPPES) confirmation for each National Provider Identifier (NPI) you list in the application package. Acceptable NPI documentation is one of the following: 1) NPI notification letter from the NPPES, 2) NPI notification e-mail from NPPES, or 3) NPI notification letter or e-mail from the Electronic File Interchange Organization (EFIO). Note: The name and business address of the applicant or provider on all forms must exactly match the name and practice location on the NPPES or EFIO notification. For information on how to apply for an NPI or update your information in NPPES, visit the Medi-Cal Web site at www.medi-cal.ca.gov, and click on the "NPI" link, or go to https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do.
You may need to submit additional documents if applicable.
Proceed to the PAVE portal.