December 12, 2017

This information was updated: Prescriber Enrollment Requirement Update (Dec. 29)

Beginning Jan. 15, 2018, the Vendor Drug Program will deny pharmacy claims for prescribing providers that are not enrolled in Texas Medicaid.  This applies to claims prescribed for people enrolled in:

  • Medicaid fee-for-service
  • The Children with Special Health Care Needs Services Program
  • Healthy Texas Women Program

Changes of note:

  • Between Jan. 15 and Apr. 16, pharmacy can submit a value of “55” (“Prescriber Enrollment in State Medicaid Program has been validated”) in the “Submission Clarification Code” field (420-DK) to override the prescriber not enrolled rejection in emergency situations.
  • As of Jan. 15 the use of hospital- or organization- prescriber National Provider Identifier will result in a claim denial.
  • Claims for 72-hour supplies will also be denied if the prescriber is not enrolled.

Pharmacy staff should review the “Ordering, Referring, and Prescribing Provider Enrollment Information” document (PDF) for information about the prescriber enrollment requirements, how to address situations when the a prescriber is not enrolled, and to download flyers that may be distributed in your store to those affected by this change.