Medicaid claims must contain the NPI of the ordering, prescribing, or referring physician or other professional

Medicaid claims must contain the NPI of the ordering, prescribing, or referring physician or other professional

Physicians that order, prescribe, or refer for Medicaid residents must be enrolled in the Medicaid program and have an NPI number. This includes Medical Directors and Attending Physicians or other professionals who order, refer, or prescribe services for a Medicaid recipient but do not directly bill Medicaid but provide these.

Claims for the payment of items or services ordered, referred and prescribed that do not include the NPI of the physician or other professional will be denied beginning on Jan. 15, 2018. Claims will also be denied if the ordering, referring or prescribing provider is not enrolled in the respective program.

NOTE:  The Health and Human Services Commission (HHSC) is allowing a three-month grace period from Jan. 15, 2018, to April 16, 2018, during which claims not meeting these requirements will be initially denied and then reprocessed to allow providers additional time to complete enrollment and minimize client and provider impact

For providers whose only relationship with Texas Medicaid is to order or refer services for Texas Medicaid clients, TMHP has developed an abbreviated enrollment application titled “Texas Medicaid Provider Enrollment Application Ordering and Referring Providers Only.” This shortened application allows providers to enroll as an ordering or referring provider without participating as a rendering or billing provider within the state Medicaid program.

Attached is the HHSC article titled “Implementation for Required Enrollment of All Ordering, Referring or Prescribing Providers as of January 15, 2018,” and “Frequently Asked Questions” that includes information about ordering, referring or prescribing provider information.