Medicaid Information for Providers

Medicaid and ROPA enrollment

Our partnership with you is vital to providing high-quality care to our most vulnerable members — those dually eligible for both Medicare and Medicaid.

To ensure seamless claims processing, we want to clarify a critical requirement regarding your enrollment status with your State Medicaid agency.

Why this matters to your practice

Even if you do not participate in the Medicaid program or intend to bill Medicaid directly for services, federal regulations (42 CFR §455.410) require state Medicaid agencies to enroll all providers who order, refer, prescribe, or attend to Medicaid beneficiaries.

Even if you do not intend to bill Medicaid directly for services, you must be enrolled in the state Medicaid program on at least a ROPA (Referring, Ordering, Prescribing, or Attending) basis if you treat members who:

Are enrolled in a Medicare Advantage Special Needs Plan (SNP), or
Receive secondary coverage through Medicaid Fee-For-Service (FFS) or a Medicaid Managed Care Organization (MCO).

The Consequences of Non-Enrollment

Failure to maintain an active Medicaid ID (even for ROPA-only purposes) results in:

Claim Denials: Automated systems may reject "crossover" claims where the performing or referring NPI is not recognized by the state.
Pharmacy Disruptions: Prescriptions written by non-enrolled providers may be denied at the pharmacy for Medicaid/dually-eligible members.
Compliance Risk: Our network is required to ensure that all providers seeing dual-eligible members meet state and federal credentialing standards.

How to comply

The ROPA enrollment process is a streamlined version of full Medicaid enrollment. It does not require you to see Medicaid-only patients or accept Medicaid's fee schedule for all your patients; it simply validates your credentials within the state system. Please visit your state Medicaid website from the list below for additional details.

We value the care you provide to our members. By completing this enrollment, you protect your practice from administrative burden and ensure our members receive their benefits without interruption.