Legal Bulletins

Need to Know:

• Beginning January 3, 2024, Maryland Medicaid programs will deny any pharmacy claim in which the prescriber is not actively enrolled in Maryland Medicaid. 
• This applies to Fee-For-Service (FFS) claims only.
• Prescribers do not need to participate with Maryland Medicaid but instead can enroll as an Ordering, Referring, or Prescribing (“ORP”) only provider who does not bill Medicaid for services or sign a full Provider Agreement with Medicaid.
• Phase 1 Denials (January 3, 2024): Medicaid will deny pharmacy claims for non-behavioral health drug classes if the prescriber is not enrolled.
• Phase 2 Denials (July 2024): Medicaid will deny ALL pharmacy claims regardless of drug class if the prescriber is not enrolled.

The Affordable Care Act requires that any ordering, referring, and prescribing (“ORP”) providers be enrolled with the state Medicaid Program. This is because the state Medicaid Program is prohibited from reimbursing claims which list an ordering, rendering, or prescribing provider who is not enrolled in Medicaid. Therefore, pharmacy claims for prescription drugs prescribed by an unenrolled prescriber must be denied at the pharmacy point-of-sale.

Prescribers who are not enrolled in Medicaid may choose to become a participating provider with Medicaid or enroll as an ORP-only provider.

Providers who enroll as participating with Medicaid submit claims to Medicaid and agree to accept Medicaid reimbursement as payment in full for covered services rendered to Medicaid beneficiaries. Alternatively,  ORP-only providers do not submit claims to Medicaid or receive payment from Medicaid. 

Providers who wish to enroll with Maryland Medicaid as either a participating provider or an ORP-only provider must complete an online application. Additional information on ORP-only enrollment is available on the Maryland Department of Health website. 

Darci M. Smith
410-576-4153 • dsmith@gfrlaw.com