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CareSourceMedicaid · Administrative · Provider Bulletin · GA · Psychiatry, Dentistry, Pharmacy +11 moreHigh impact

[Georgia] 2025 Order, Prescribe and Refer (OPR) Update

Act
by Jan 31, 2025
Effective date
Feb 1, 2025
Identified
May 9, 2026

Summary

Georgia Medicaid is implementing revised OPR (Order, Prescribe and Refer) provider enrollment requirements effective February 1, 2025. Claims billed with OPR provider numbers for independently rendered services will be denied. New billing requirements mandate that specific claim types include valid, active OPR-registered referring/ordering/attending provider NPIs, with strict rules prohibiting OPR-only providers from billing as rendering providers and preventing the same physician from being listed as both rendering and ordering/referring provider.

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What to do

by Jan 31, 2025 · 9 steps
01Billing team must audit all provider NPIs in the system to ensure OPR providers are valid, active on the 7400 file, and registered as OPR type.
02Update billing system validation rules to REJECT claims that bill OPR-only specialty type providers as rendering providers.
03Configure system to REJECT claims where the same NPI appears as both rendering provider AND ordering/referring provider.
04For inpatient claims (except 18x/28x swingbed), 14x hospital other, and 81x-83x special facilities: require and validate Referring or Attending NPI on all claims.
05For 71x/73x clinic claims with lab (80001-89399), radiology (70002-79999), or consultation (99241-99255) codes: require and validate Referring or Ordering NPI.
06For all specified provider types (13-Dietary, 18-Pharmacy, 28-Hospital, 29-Labs, 30-MCO, 33-Medical Supplier, etc.): require valid Referring or Ordering NPI with proper 7400 file registration.
07Ensure attending physician NPIs reflect the actual attending provider's name and identifiers, NOT group information.
08Train providers and billing staff on new requirements.
09Before February 1: Test billing system changes with sample claims.
If missed: Failure to comply will result in claim denials for both fee-for-service and CMO claims.

Codes mentioned

8000189399700027999999241992429924399244992459925199252992539925499255V2500V2510V2513V2520V2523V2755

Original notice

[Georgia] 2025 Order, Prescribe and Refer (OPR) Update
caresource.com · Always check the source before changing claims.
View original ↗

Related changes

See all CareSource changes →
[Georgia] 2025 Order, Prescribe and Refer (OPR) UpdateHighEffective Feb 1, 2025 · Provider Bulletin[Ohio] OAC Rule 5160-1-17.9 Ordering, Referring and Prescribing ProvidersHighEffective Jan 1, 2027 · Provider Bulletin[Georgia] 2025 Order, Prescribe and Refer (OPR) UpdateHighEffective Feb 1, 2025 · Provider BulletinBrowse every CareSource change in the policy list

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CareSource policiesGA policy changesPsychiatryDentistryPharmacyOphthalmologyOptometryPodiatrySpeech TherapyOccupational TherapyPhysical TherapyGeneral PracticeEmergency MedicineChiropracticPalliative CareRadiologyCode 80001Code 89399Code 70002Code 79999Code 99241Code 99242Code 99243Code 99244Code 99245Code 99251Code 99252Code 99253Code 99254Code 99255Code V2500Code V2510Code V2513Code V2520Code V2523Code V2755

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