Provider Classification

  All providers fall into one of the following four classifications for claims submission and reimbursement purposes.
  Please choose from one of the following classifications when performing the enrollment function.

Billing Provider – A sole practitioner, business entity, or facility with no other rendering providers or practitioners reporting services using the same tax id number.  The sole practitioner, business entity, or facility bills and receives payment in its own name.  Examples of Billing Provider types include, but are not limited to, hospitals, long-term care facilities, transportation providers, solo practice physicians that are not part of a group, pharmacies, and Durable Medical Equipment businesses.

Group Provider – A business or practice entity which bills and receives payment for services furnished by one or more practitioners or rendering providers linked to the practice or entity.  The practitioners or rendering providers reassign their benefits to the Group Provider.  Examples of Group Provider types include, but are not limited to, clinics, physician multi-specialty groups, optometrists, and chiropractors.

Rendering Provider – A practitioner or other performing provider with an employment or contractual relationship with a Group Provider.   The rendering provider does not bill and receive payment in his/her own name.  The group provider bills and is reimbursed for the service performed at the group practice or clinic.  A rendering provider can be associated with multiple groups, at multiple locations or practice sites.

Ordering, Prescribing, Referring (OPR) Only - Providers that only order, prescribe, or refer services for IHCP members are classified as OPR providers.  OPR providers must be enrolled enrolled in the IHCP.  OPR providers do not bill the IHCP for the services.  Services are billed by a receiving provider such as a pharmacy or specialist and must include the NPI of the provider that ordered, prescribed, or referred service on the claim.  If the NPI listed in the ordering, prescribing, or referring provider field of the claim is not enrolled as a regular rendering provider or an OPR provider, the receiving provider will not be reimbursed for the service.  IHCP enrolled rendering providers may already order, prescribe, and refer and do not need to complete the OPR enrollment.