November 6, 2017

Beginning Jan. 15, 2018, claims for the payment of items and services ordered, referred or prescribed, must contain the National Provider Identifier (NPI) of the physician or other professional who ordered, referred or prescribed the items or services. Additionally, all ordering, referring or prescribing providers must be enrolled as participating providers in Texas Medicaid.  These requirements only impact the traditional Medicaid, the Healthy Texas Women (HTW) Program, and the Children with Special Health Care Needs (CSHCN) Services Programs. These requirements do not apply to out-of-network providers that order, refer, or prescribe only for people enrolled in managed care.

Claims for the payment of items or services ordered, referred and prescribed that do not include the NPI of the physician or other professional who ordered, referred or prescribed the items or services will be denied beginning Jan. 15. Claims will also be denied if the ordering, referring, or prescribing provider is not enrolled in the respective program. Pharmacies will not be able to substitute a missing prescriber NPI with the facility NPI or NPI of another provider who did not directly treat the client.

HHSC is allowing a three-month grace period, from Jan. 15 to Apr. 16, 2018, during which time pharmacies will be able to submit a submission clarification code to bypass rejections when a prescriber is not enrolled. VDP will provide more guidance to pharmacies in the coming weeks.

Except for out-of-network providers who order items or services for poeple enrolled in managed care, all providers who order, refer, or prescribe for clients enrolled in Medicaid, HTW, or the CSHCN Services Program should begin the enrollment process immediately by completing the online application.

These requirements were initially announced on Jul. 15, 2016, and were to be effective on Oct. 1, 2017.  HHSC delayed the effective date to Jan. 15 as a result of Hurricane Harvey. These new requirements are necessary to ensure compliance with federal regulations 42 CFR Sections 455.440 and 455.410.

Interns and Medical Residents

Interns cannot enroll and medical residents are not required to enroll in Texas Medicaid. For interns and residents who are not enrolled in Texas Medicaid:

  • His or her licensed supervising physician must be reported as the ordering, referring or prescribing provider, and
  • The NPI of the supervising physician must be listed on orders, referrals or prescriptions written by the interns or medical residents they supervise.

To be eligible for payment, the supervising physician or clinician's NPI must be included on claims for items or services that the intern or resident ordered, referred or prescribed. These requirements impact the Medicaid, HTW, and the CSHCN Services programs only.  These requirements do not apply to out-of-network providers that order, refer, or prescribe only for people enrolled in managed care.

For additional information, prescribing providers can call

  • TMHP Contact Center at 1-800-925-9126
  • TMHP-CSHCN Services Program Contact Center at 1-800-568-2413