Prescribing Provider Identifier
Claims for the payment of items and services ordered, referred or prescribed must be enrolled as a participating provider and contain the National Provider Identifier (NPI) of the physician or other professional who ordered, referred or prescribed the items or services will be denied. These requirements only impact programs for traditional Medicaid, CSHCN Services Program, and HTW Program. Out-of-network providers ordering, referring, or prescribing only for people enrolled in managed care are not subject to these requirements.
Pharmacies cannot substitute a missing prescriber NPI with the facility NPI or NPI of another provider who did not directly treat the person. This includes claims processed for a 72-hour emergency supply. Refer to the Claims Billing (B1) Transaction payer sheets for specific transaction, segment, and field requirements.
| Field Number | Field Name | Values | Usage |
|---|---|---|---|
| 411-DB | Prescriber ID | 10 - digit Prescriber NPI | R |
| 466-EZ | Prescriber ID Qualifier | 01 - National Provider Identifier | R |
| 427-DR | Prescriber Last Name | Last Name | O |
Medicaid-enrolled prescribers and allowed practitioners can sign prior authorizations and order covered Medicaid home health services, including durable medical equipment and supplies. An allowed prescriber is a physician assistant or an advanced practice registered nurse licensed as a certified nurse practitioner (CNP) or clinical nurse specialist (CNS).
HHSC adopted rules in alignment with 42 CFR Section 440.70 (Home Health Services). The following amendments to 1 TAC Chapter 354 (Medicaid Health Services) became effective on Sept. 21, 2022:
- Section 354.1031: General
- Section 354.1035: Recipient Qualifications for Home Health Services
- Section 354.1037: Written Plan of Care
- Section 354.1039: Benefits and Limitations of Home Health Services
- Section 354.1040: Requirements for Wheeled Mobility Systems
- Section 354.1043: Competitive Procurement of Durable Medical Equipment (DME) and Supplies
Prescribing providers must enroll with HHSC through the Provider Enrollment and Management System (PEMS) before providing outpatient Medicaid prescription services. HHSC loads the following prescribing provider types into the VDP claims system to process claims:
- Medical doctors (MD)
- Doctor of Dental Surgery (DDS)
- Doctor of Osteopathic Medicine (DO)
- Doctor of Podiatry (DP & DPM)
- Advanced Practice Registered Nurses (APRN)
- Prescribing Pharmacist (PH)
- Physician Assistants
- Therapeutic Optometrist & Glaucoma Specialist (OD & OGD)
Pharmacy claims submitted to HHSC without a valid NPI will reject. Refer to the National Plan and Provider Enumeration System (NPPES) NPI Registry if the prescriber’s NPI is not found.
The Prescriber Search (txvendordrug.com/providers/prescriber-search) provides name, address, and other demographic information about all Medicaid-enrolled prescribing providers.
HHSC updates the search weekly, usually every Monday morning. The data used in the search is also available for download as a delimited text file. Refer to the VDP Website Handbook for search instructions and information about the data.