Ordering Prescribing Referring (OPR) Provider Rules

Did you know? Depending on your state, OPR is referred to as Referring Ordering Prescribing Attending (ROPA) or Ordering Referring Prescribing (OPR) .

Title 42, Code of Federal Regulation, includes two rules for OPR providers: 

  • § 455.410 Enrollment and screening of providers (b) The State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the state plan or under a waiver of the plan to be enrolled as participating providers. 
  • § 455.440 National Provider Identifier The State Medicaid agency must require all claims for payment for items and services that were ordered or referred to contain the National Provider Identifier (NPI) of the physician or other professional who ordered or referred such items or services. 

Envolve Benefit Options follows state guidance and direction regarding registration requirements and NPI inclusion rules; therefore, claims may deny if the ordering or prescribing provider is not included on applicable claims.

Confirm your state’s rules for OPR by visiting your state’s website:

Log in to the Eye Health Manager to find the provider manual : here you’ll find detailed instruction on where to include the NPI on your claim. If you’re using the CMS 1500 form, OPR information is included in boxes 17 and 17b. 

  • Box 17: Name of Referring Provider or Other Source
  • Box 17b: National Provider Identifier (NPI)