April 23, 2018
Federal regulation 42 CFR Section 455.410 requires all ordering, referring, or prescribing providers to be enrolled as participating providers in Medicaid. This requirement does not impact Medicaid managed care or CHIP claims.
Between Jan. 15 and April 29, the Vendor Drug Program (VDP) allowed pharmacies to submit a code to override the prescriber enrollment denial in emergencies when the prescribing provider is not enrolled.
VDP will discontinue the override as of April 30. Starting April 30 and continuing until July 27, pharmacies should contact the HHSC Pharmacy Benefits Access Help Desk at 1-800-435-4165 to obtain a manual override of the prescriber enrollment denial. The Help Desk will only override a denial one time per person per prescriber. After a person has received an override for a medication prescribed by a particular prescriber who is not enrolled, no more overrides will be available to that person for any additional prescriptions written by the same non-enrolled prescriber. People will be able to get an override for medication prescribed by another non-enrolled prescriber. When a denial is received and an override is not available, pharmacies should inform the person that his or her prescriber must be enrolled. The help desk’s hours of operation are Monday through Friday, 8:30 a.m. to 5:15 p.m. central time. More information about ordering, referring, and prescribing provider enrollment is available at www.tmhp.com.
Prescribing Pharmacist Enrollment
Beginning May 18, 2018, prescribing pharmacists are able to enroll in Texas Medicaid as an ordering, referring, or prescribing provider. In accordance with federal regulation 42 CFR 455.410., prescribing pharmacists who write prescriptions for Texas Medicaid fee-for-services clients must enroll as an ordering, referring, or prescribing provider. Refer to the TMHP website for more information.
To allow prescribing pharmacists time to enroll with TMHP, VDP will not deny pharmacy claims when the prescribing pharmacist is not enrolled until Aug. 20, 2018.