MedicaidAdministrativeHigh impact
[Georgia] 2025 Order, Prescribe and Refer (OPR) Update
CareSource·GA · Psychiatry, Dentistry, Pharmacy +11 more·Provider Bulletin
Effective date
Feb 1, 2025
We identified it
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.
Action Required
By January 31, 2025: (1) Billing 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. (2) Update billing system validation rules to REJECT claims that bill OPR-only specialty type providers as rendering providers. (3) Configure system to REJECT claims where the same NPI appears as both rendering provider AND ordering/referring provider. (4) For inpatient claims (except 18x/28x swingbed), 14x hospital other, and 81x-83x special facilities: require and validate Referring or Attending NPI on all claims. (5) For 71x/73x clinic claims with lab (80001-89399), radiology (70002-79999), or consultation (99241-99255) codes: require and validate Referring or Ordering NPI. (6) For 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. (7) Ensure attending physician NPIs reflect the actual attending provider's name and identifiers, NOT group information. (8) Train providers and billing staff on new requirements. (9) Before February 1: Test billing system changes with sample claims. Failure to comply will result in claim denials for both fee-for-service and CMO claims.