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Medicaid Ordering, Referring and Prescribing Providers: Pharmacy Update
Act
by Dec 1, 2026
Effective date
Dec 1, 2026
Identified
Oct 3, 2026
Summary
South Carolina Medicaid is implementing a hard enforcement of ORP (Ordering, Referring, and Prescribing) provider enrollment requirements for pharmacy claims effective December 1, 2026. Starting that date, pharmacy claims submitted without the prescriber's National Provider Identifier (NPI) will be rejected and not paid. Pharmacies can request one-time claim rejection overrides by contacting the fee-for-service pharmacy technical help desk.
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What to do
by Dec 1, 2026 · 6 steps
01Billing and pharmacy staff must ensure all pharmacy claims submitted to South Carolina Healthy Connections Medicaid include the prescriber's National Provider Identifier (NPI).
02Verify that all ordering, referring, and prescribing providers (including pharmacists providing reimbursable covered services) are enrolled as Medicaid providers with SCDHHS.
03Update billing system edits and claim submission workflows to require and validate NPI field population before claim submission.
04Train pharmacy staff on the rejection process: if claims are rejected starting December 1, 2026, pharmacy staff can contact the fee-for-service pharmacy technical help desk at (866) 254-1669 (available 24/7) for a one-time claim rejection override.
05Failure to include valid prescriber NPI will result in automatic claim denials and non-payment.
06Recommend pharmacy staff and providers attend ORP training offered in October or November 2026 via www.medicaidelearning.com or (888) 289-0709.
Original notice
Medicaid Ordering, Referring and Prescribing Providers: Pharmacy Update
scdhhs.gov · Always check the source before changing claims.