By Carla Cox

Texas Medicaid providers that receive referrals from non-participating physicians or other health care providers need to be aware that beginning January 1, 2013, individual providers who are not currently enrolled in Texas Medicaid and whose only relationship with Texas Medicaid is to order or refer supplies or services for Texas Medicaid-eligible clients must enroll in Texas Medicaid as participating providers in accordance with provisions of the Affordable Care Act of 2010 (ACA).

The Code of Federal Regulations (CFR) Title 42 §455.410(b) requires all ordering or referring physicians or other professionals who order or refer supplies and services under the Medicaid State plan, or under a waiver of the plan, to enroll in Medicaid as participating providers.

Although ordering and referring providers will not submit claims to Texas Medicaid, the ordering and referring provider's National Provider Identifier (NPI) will be required on claims that are submitted by the providers that render the supplies or services.

Impact on Provider Claims Filing

Beginning January 1, 2013, all claims for services that require a physician order or referral must include the ordering or referring provider's NPI. Claims with dates of service on or after January 1, 2013, that are submitted without the ordering or referring provider's NPI may be subject to retrospective review and denial if the NPI is not included on the claim.

Pursuant to a notice issued by the Texas Medicaid & Healthcare Partnership ("TMHP"), the billing provider must submit the ordering or referring provider's NPI on claims beginning January 1, 2013, even if the ordering or referring provider is not yet enrolled in Texas Medicaid. The billing provider will be responsible for confirming that the ordering or referring provider has begun the enrollment process with TMHP.

For example, in the past a physician could provide an order to a Medicaid durable medical equipment ("DME") supplier for covered durable medical equipment even if the physician did not participate in the Texas Medicaid program. Under the new rules, the physician will need to make application to enroll in the Texas Medicaid program in order for the DME supplier to be paid by Medicaid for the equipment provided pursuant to the physician's order.

After a suitable period of time to allow for ordering- or referring-only providers to complete the enrollment process, claims will be subject to denial if the ordering or referring provider is not enrolled in Texas Medicaid. Providers will receive a minimum 45-day advance notice before claim denials will begin.

The billing provider will be responsible for confirming that an ordering or referring provider is enrolled in Texas Medicaid.

According to TMHP additional information regarding this new requirement will be furnished in future articles on the TMHP website. 

If you have any questions about this e-Alert, please contact Carla Cox at 512.236.2040 or cjcox@jw.com.