Prescribers and Billing Providers FAQ
Providers who prescribe medications, order tests, and/or refer Medi-Cal members for other services, must be enrolled with Medi-Cal. If a prescriber is not enrolled or their information is missing or out of date, there may be a delay in Medi-Cal members receiving their medications and/or services. If ordering or referring providers are not enrolled or their information is missing or out of date, there may be a delay in Medi-Cal members receiving their services. These questions and answers provide more information for prescribers and billing providers on potential impacts and steps that can be taken to address.
General Information
Who are ORP providers?
A. ORP providers are licensed clinicians who order, refer, or prescribe services or items for Medi‑Cal members.
- Ordering providers direct services such as lab tests, DME, or home health.
- Referring providers send members to another clinician for evaluation or treatment they cannot provide.
- Prescribing providers write prescriptions for medications or pharmacy‑dispensed items.
For specialty behavioral health, many Licensed Practitioners of the Healing Arts and Licensed Mental Health Professionals also function as ordering providers and must enroll. (See the FAQ for the full list.)
Why was my claim delayed or denied?
Claims can be delayed or denied when the ordering, referring, or prescribing provider is not enrolled in Medi-Cal, or when the provider’s Type 1 NPI is missing, invalid, or not entered where required on the claim.
What do I do if a Medi-Cal member urgently needs a medication?
Pharmacies can authorize an emergency fill at point of sale. Emergency fills are permitted for a 14-day supply twice within a 30-day period. More information can be found in the provider manual referencing 15.7.1 Emergency Dispensing of 14-Day Supply. More information can be found in the Medi-Cal Rx Provider Manual, Section 15.7.1 Emergency Dispensing of 14-Day Supply.
Is this a new requirement?
Federal regulations have required providers to be properly enrolled and clearly identified on Medi‑Cal claims since 2013, but enforcement has not always been consistent across the pharmacy (Medi‑Cal Rx), medical (CA‑MMIS), and behavioral health (Short Doyle) systems. Aligning these requirements across systems strengthens program integrity, ensures accurate identification of prescribers, reduces billing errors, and supports compliant, uninterrupted care for members. By applying these rules uniformly, DHCS meets federal mandates while improving clarity and accountability for providers and partners.
Do providers need to do anything?
Yes. Providers who order, refer, or prescribe for Medi-Cal members must be enrolled in Medi-Cal using their individual Type 1 NPI by applying using the online enrollment portal. Please see more information about the enrollment process. Enrolling as soon as possible helps avoid claim denials, billing issues, and delays in member access to medications or services. Billing providers should also verify that the ordering/referring/prescribing provider is enrolled and that a valid Type 1 NPI is included on all claims before submission.
Why is my claim denied if I am enrolled in Medi-Cal?
A claim may be denied if it requires an order, referral, or prescription and the ordering, referring, or prescribing provider is not enrolled in Medi-Cal or not correctly identified, even if the billing provider is enrolled. For denials not related to Medi-Cal enrollment, please refer to the Medi-Cal Rx Provider Manual.
How do providers enroll in Medi-Cal?
Providers must enroll in Medi-Cal through DHCS PED online enrollment application (system using their individual Type 1 NPI).
How long does enrollment take?
Applications from physicians typically will be reviewed within 90 days, and applications from all other license types are typically reviewed within 180 days. Waiting too long to enroll increases the risk of claim denials once the updated claim edits are enforced.
When will this take effect?
Claim edits will be introduced in groups beginning in the first quarter of 2027 across pharmacy, medical, and behavioral health claims. We’re using a multi-year approach to balance the need for compliance with the need to minimize disruption to members and providers. It’s also an approach driven by data and early and frequent communication with stakeholders. To see more detailed information about the enforcement timeline, refer to the September 2026 Town Hall presentation.
Will all claims be affected at once?
No. Claim edits will roll out incrementally and impact providers at different times. Providers should apply as soon as possible to ensure that the enrollment process is complete prior to their relevant enforcement implementation date.
Who can I contact if I need help with enrollment?
For enrollment or program-related questions, contact the DHCS Provider Enrollment Division through the Provider Inquiry Form.
How is DHCS preparing providers for the upcoming policy changes?
DHCS is contacting providers who are not yet enrolled, sharing guidance with MCPs, and working with licensure boards, trade groups, and stakeholder organizations to raise awareness and help providers enroll. DHCS held stakeholder Town Halls on July 30, 2026 and September 24, 2026, as well as smaller stakeholder meetings in August to gather feedback, support implementation planning, and communicate timelines for enforcement.
When will DHCS announce the date by which enforcement will begin?
DHCS announced enforcement timing at a second Town Hall on September 24, 2026. This included the rollout plan for pharmacy, behavioral health, and medical claim edits. Providers should not wait—enroll now using your Type 1 NPI to avoid delays or claim denials when enforcement starts. Providers who are not enrolled with their Type 1 NPI, should submit their application as soon as possible to the Department via the instructions provided on DHCS’ Ordering/Referring/Prescribing Only Enrollment Information webpage.
I understand that provider non-enrollment will result in claim denial once enforcement begins. Are there other consequences for not enrolling?
Yes. Once enforcement begins, prior authorization (PA) requests for pharmacy benefits will be denied if they are submitted by an unenrolled prescriber. Some ‘receiving’ providers may start verifying enrollment for the providers who refer to them before scheduling appointments or providing services for Medi-Cal members. For example, a specialist may not accept a referral from a non-enrolled provider. Likewise, a clinical lab that receives an order may not run the needed tests if they are submitted by a non-enrolled provider, as the NPI on the claim will not be eligible for processing.
Enrollment Requirements
Where can I find information about Medi-Cal provider enrollment?
DHCS’ Provider Enrollment Division (PED) is responsible for the enrollment for ORPs.
Visit DHCS’ Ordering/Referring/Prescribing (ORP) Enrollment pages and the Application Information by Provider Type page. For questions, submit a request through the Provider Inquiry Form.
How can I verify my enrollment status?
Use the list of Enrolled Medi-Cal Fee-for-Service (FFS) Providers (MediCal Dental FFS Provider Listing – Dataset – California Health and Human Services Open Data Portal for dental providers)to check whether you are currently enrolled as a Medi-Cal FFS provider. Once on the page, scroll down to the search field on the right and enter your Type 1 NPI to verify your Medi-Cal FFS provider enrollment status.
If your Type 1 NPI is found on the list, then your Medi-Cal FFS enrollment requirement specific to ordering, referring and prescribing has been met and no further action is required. If your Type 1 NPI is not found on the list, then you will need to submit a Medi-Cal FFS provider enrollment application with the DHCS PED as soon as possible to allow sufficient time for processing.
Where can I find my National Provider Identifier (NPI) type?
Use the National Plan and Provider Enumeration System (NPPES) NPI Registry to verify your NPI.
Does being contracted with a Medi-Cal MCP or enrolled in the federal Medicare program satisfy Medi-Cal provider enrollment requirements for ordering, referring and prescribing?
No. Being contracted with a Medi-Cal MCP and/or enrolled as a provider with the federal Medicare program does not satisfy the requirements for California’s Medi-Cal FFS provider enrollment to order, refer, or prescribe. You must separately apply and be approved by DHCS PED with your Type 1 NPI.
Are out-of-state providers who see Medi-Cal members required to enroll?
Providers who care for Medi-Cal members on a routine basis (not emergency care only) are required to enroll in Medi-Cal. PED can enroll providers in border communities outside California.
Does this requirement apply to pharmacists?
Yes, pharmacists prescribing under their scope of authority must be enrolled as a Medi-Cal provider with their Type 1 NPI.
Are interns and residents in training programs required to enroll in Medi-Cal?
Yes, once they have a post‑graduate training license (PTL) or full license. Non‑licensed trainees must use the NPI of a supervising enrolled provider.
Are Community Health Workers (CHWs) and Community Perinatal Health Workers (CPHWs) required to enroll as ORP providers? We do not see these provider types available as options for enrollment.
No. ORP enrollment is individual and not tied to any employer.
We have a County Behavioral Health Network that is split into Mental Health and Drug Medi-Cal Organized Delivery System (DMC-ODS). Are DMC-ODS providers required to enroll as ORP providers, or will affiliation through their facility suffice?
All providers who are writing orders, referrals, or prescriptions must be enrolled under their Type 1 NPI. If they are already enrolled with their Type 1 NPI through their affiliation with the facility, they do not need to complete a separate ORP enrollment.
Do California-certified Alcohol & Other Drug Counselors need to enroll as ORP providers?
No. The NPI of the enrolled licensed clinician that writes the order, referral, or prescription will be used on the claim.
Do school nurses or licensed educational psychologists need to enroll as ORPs if employed by the Local Education Agency (LEA)?
No, school nurses and licensed educational psychologists are not eligible to enroll.
Can registered nurses enroll as an ORP provider?
Registered nurses are not eligible to enroll.
I was asked to enroll as an ORP provider by my hospital, but the application did not ask for my hospital affiliation, just my outpatient clinic. Will this be linked to the hospital through my NPI for their reimbursement?
This type of enrollment is not affiliated with any other organization, including hospitals, and there is no process to link your enrollment to a hospital NPI.
If I am enrolled as a rendering provider, do I need to enroll as an ORP provider also?
No. If you are currently enrolled with your Type 1 NPI, including enrollment as a rendering provider, you do not need to enroll using the ORP enrollment type.
Do I need to enroll as both an ORP provider and a FFS provider?
If you are enrolled with Medi-Cal as an ORP provider with your Type 1 NPI, you are recognized as an individual FFS Medi-Cal enrolled provider. The ORP provider enrollment is one type of FFS enrollment.
Do all prescribing providers enroll as ORP providers or are there alternate provider classifications or categories under which providers can enroll?
All prescribing providers need to complete an enrollment using their Type 1 NPI. Prescribers may be enrolled as a rendering provider, non-physician medical practitioner (NMP) provider, a sole proprietor billing provider, or ORP-only provider.
If I enroll with Medi-Cal, am I required to provide care to Medi-Cal members? Does this requirement come with additional responsibilities such as treating a minimum number of Medi-Cal members?
No. Enrolling with Medi-Cal solely to order, refer or prescribe, does not bind you to any additional responsibilities with respect to caring for one or more Medi-Cal members.
I’ve already enrolled with Medi-Cal Rx and am having no issues getting medications for my Medi-Cal patients. Is that sufficient?
Enrollment with Medi-Cal Rx provides access to the Medi-Cal Rx Provider Portal, but is not sufficient to meet Medi-Cal provider enrollment requirements. With enforcement of federal regulation, Medi-Cal members will no longer be able to obtain their prescriptions written by non-enrolled providers.
I practice in multiple counties. Am I required to complete an application for each county?
If submitting an ORP enrollment application, you only submit one application.
If a newly hired provider had already enrolled with their prior employer, do they have to re-enroll?
If you enrolled as an ORP provider, you are not currently required to report when you change employers. The ORP provider enrollment is an individual enrollment that is not linked/affiliated to a specific employer or address.
Do enrolled providers need to re-validate and if so, how often?
Yes. Federal rules require revalidations at least every five years. Providers will be notified when they are due for revalidation.
Enrollment Process
What is the typical processing time for Medi-Cal FFS provider enrollment applications submitted to DHCS’ PED?
Physician applications will typically receive a response within 90 days. All other license types (such as nurse practitioner or physician assistant) will receive a response typically within 180 days. Applications are processed as quickly as possible in the order that they are received. Note that some applications may require additional information in order to be processed, which can result in processing delays.
Will DHCS backdate the effective date to the date the application was submitted?
In most cases, the effective date of enrollment is the date the complete application is received, unless otherwise specified in regulation. For the ORP provider enrollment type, the effective date is one year prior to the date the application is received. However, if the provider did not hold a valid professional license at that time, the enrollment effective date will be the date the license was issued.
Can administrative staff (such as an office manager) submit Medi-Cal FFS provider enrollment applications for one or more providers or does each individual provider need to submit their own Medi-Cal FFS provider enrollment application?
Administrative staff, such as an office manager, can prepare an application on the provider’s behalf, but the provider must create their own unique username and password to access the Medi-Cal FFS provider enrollment application to review the information and to complete the provider agreement and signature. Signatures cannot be delegated to any other person.
Are all providers subject to the $750.00 application fee to enroll with Medi-Cal?
There is no fee associated with an ORP provider application. Individuals are not subject to the application fee.
Pharmacy/Medi-Cal Rx Billing
How should pharmacies prepare for enforcement?
Pharmacies already receive warning messages when a prescriber is not enrolled. They should notify prescribers and encourage them to enroll before enforcement begins in 2027.
In an emergency situation, can an emergency pharmacy claim be reimbursed if the prescriber is not enrolled?
Yes—up to a 14‑day supply, twice within 30 days, using “Emergency” Level of Service at point-of-sale.
Can a Medi-Cal member pay out-of-pocket for a prescription delayed or denied due to prescriber non-enrollment? If yes, is the expense reimbursable with a Conlan claim?
No. Claims denied due to prescriber non-enrollment are not eligible for reimbursement.
If an Ordering/Referring/Prescribing (ORP) provider’s Medi‑Cal enrollment application is approved with a retroactive effective date, are prescription claims considered valid when they were paid before the provider submitted the ORP application but after the backdated enrollment effective date?
Yes, if the date of service is on or after the retroactive effective date. Claims may still be reviewed for other requirements.
Medical/CA-MMIS Billing
Which NPIs must be included on Medi-Cal claims for Medi-Cal covered goods and/or services ordered and/or referred by another provider?
- Providers billing for Medi-Cal covered services through the Internet Professional Claims Submission (IPCS) application, see IPCS User Manual. User Guide_Internet Professional Claim Submission (IPCS) User Guide (ipcs_ipc00)
- Providers billing for Medi-Cal covered services through the 837 transactions, see appropriate 837 companion guide. Electronic Data Interchange (EDI) 837 Claims Overview (edi 837 claims)
- Providers billing for Medi-Cal covered services on a paper CMS 1500 claim form, see CMS1500 comp in the Medi-Cal provider manual. CMS-1500 Completion (cms comp)
- Providers billing for Medi-Cal covered services on a paper UB04 claim form for Outpatient services, see UB04op comp sections in the Medi-Cal provider manual. UB-04 Completion: Outpatient Services (ub comp op)
- Providers billing for Medi-Cal covered services on a paper UB04 claim form for Inpatient services, see UB04ip comp sections in the Medi-Cal provider manual. UB-04 Completion: Inpatient Services (ub comp ip)
Billing providers must include an Ordering and/or Referring Type 1 NPI 1, depending on provider type and policy requirement, when completing claims forms.
If I am part of a larger organization, do I need to submit an Ordering and/or Referring NPI on the claim?
If the organization is the biller, an NPI Type 1 (individual) Ordering and/or Referring must be on the claim.
How does the ORP enrollment requirement apply when multiple providers are involved in a DME referral?
Yes, each provider performing an ordering, referring, or prescribing function must maintain active Medi-Cal enrollment with their Type 1 NPI to avoid claim denials.
Is a license number or EITN acceptable on the Medi-Cal claim as an alternative to the Ordering and/or Referring NPI?
No, a valid, actively enrolled Medi-Cal participating 10-digit NPI for the date of service billed must be on the claim.