Provider Alert! FAQS: Ordering, Referring, and Prescribing ProvidersTexas Children's Health Plan
Ordering, Referring, and Prescribing Providers Frequently Asked Questions
1) What is the new enrollment requirement for ordering, referring, and prescribing
–– Federal regulations at 42 CFR 455.440 require claims for payment of items or services that were ordered, referred or prescribed to contain the National Provider Identifier of the physician or other professional who ordered, referred or prescribed the items or services. Additionally, federal regulation 42 CFR 455.410 requires all ordering, referring or prescribing providers to be enrolled as participating providers in Medicaid. This requirement includes prescription drugs dispensed at a pharmacy.
–– Starting Oct. 1, 2017, Texas Medicaid will deny claims for items and services ordered, referred or prescribed for any Medicaid, Children with Special Health Care Needs Services Program, or Healthy Texas Women client when the provider who ordered, referred or prescribed the items or services is not enrolled in Texas Medicaid.
–– Starting Oct. 16, 2017, Texas Medicaid will deny Medicaid, Children with Special Health Care Needs and Healthy Texas Women pharmacy claims for drugs when the prescribing provider is not enrolled in Texas Medicaid.
2) I am enrolled as a physician/Advanced Practice Registered Nurse/Physician Assistant in a group practice, and my services are billed through by group practice. Do I need to enroll as an ordering, referring or prescribing provider?
–– No, you are already enrolled in Medicaid as required by federal regulations. You will be able to use your existing National Provider Identifier for orders and referrals.
3) I am employed as a physician/APRN/PA with a Rural Health Clinic, and my services are billed through the clinic. Do I need to enroll as an ordering, referring or prescribing provider?
–– Yes, since you have not been individually screened and enrolled in Medicaid, you will need to enroll for the purposes of ordering or referring services for your patients. It is not appropriate to use the clinic’s National Provider Identifier for orders or referrals. The same is true for providers employed by a Federally Qualified Health Center.
4) Are hospitalists required to enroll as ordering, referring or prescribing providers?
–– Yes, hospitalists who write prescriptions, make referrals or orders for a Medicaid client must enroll in Medicaid. Medicaid clients who receive a prescription written by a hospitalist will not be able to get the prescription filled at a pharmacy if the hospitalist is not enrolled.
5) Are interns or medical residents required to enroll as ordering, referring or prescribing providers?
–– No, interns or medical residents aren’t required to enroll in Texas Medicaid. Services which are ordered, referred or prescribed by an intern or medical resident may use the National Provider Identifier of their supervising physician or licensed clinician as the ordering, referring or prescribing provider. However, should the intern or medical resident choose to enroll, that National Provider Identifier may be reported as the ordering, referring or prescribing provider on claims.
–– If the intern or medical resident isn’t enrolled and the supervising physician or licensed clinician is to be reported as the ordering, referring or prescribing provider, then the National Provider Identifier of the supervising physician or licensed clinician must be listed on orders, referrals or prescriptions written by interns or medical residents they supervise.
6) Which provider types are allowed by law to prescribe in Texas?
–– In Texas, only physicians (MDs or DOs), dentists (DDSs), podiatrists (DPMs) or veterinarians (DVMs) may issue most prescriptions.
–– Therapeutic optometrists may also issue prescriptions for certain topical medicines for the eye. If the optometrist is properly certified as an optometric glaucoma specialist, they may also prescribe certain oral medicines.
–– Advanced practice nurses or physicians assistants may issue certain prescriptions under a written protocol from a supervising physician and within their scope of practice. Advanced practice nurses include certified nurse midwives, certified registered nurse anesthetists, and nurse practitioners/clinical nurse specialists.
7) How will my patients be affected if I don’t enroll?
–– If your patient receives services through Medicaid, CHIP, Healthy Texas Women or Children with Special Health Care Needs and you write a prescription for that patient, they will not be able to fill the prescription at the pharmacy.
–– Providers of other services (i.e. durable medical equipment, medical supplies, lab or radiology services, etc.) won’t be reimbursed for services they provide if you aren’t enrolled. You might receive calls from these providers asking that you complete the enrollment so that their claim can be paid. This might eventually result in these providers not accepting your orders and your patients not receiving the services you ordered.
8) When should I submit my enrollment application to ensure enrollment is completed by Oct. 1, 2017?
–– Providers need to submit their enrollment applications as soon as possible.
9) How do I apply for ordering, referring or prescribing enrollment?
–– To complete the application electronically, visit https://secure.tmhp.com/ProviderEnrollment
–– To complete the paper application, click here.
and mail the completed application form to:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
P.O. Box 200795
Austin, TX 78720-0795
10) I’m not sure if I am currently enrolled in Medicaid. How can I confirm my enrollment
–– Call the TMHP Contact Center, 800-925-9126.
11) Does this requirement apply to managed care and traditional fee-for-service
–– Yes, it applies to both.
12) Does this requirement apply to CHIP?
–– The requirement for ordering and referring provider enrollment will apply to CHIP on Jan. 1, 2018. On Jan. 1, 2018 managed care organizations will deny CHIP claims if the ordering and referring provider isn’t enrolled.
13) Does this requirement apply to the Healthy Texas Women program?
–– Yes, Health Texas Women providers must receive their orders, referrals and prescriptions from Medicaid-enrolled providers starting Oct. 1, 2017 for claims paid by TMHP and Oct. 16, 2017, for pharmacy claims paid by the Vendor Drug Program.
14) Does this requirement apply to claims submitted for dual-eligible Medicare-Medicaid
–– Providers who order, refer or prescribe Medicare covered services for dual-eligible clients, defined as Qualified Medicare Beneficiaries, Medicaid Qualified Medicare Beneficiaries. won’t need to enroll in Medicaid. However, Medicaid only services ordered, referred or prescribed will require the ordering provider to be enrolled in Medicaid. If Medicare is the primary payer and Medicaid pays cost-sharing amounts, then the provider isn’t required to enroll in Medicaid. If Medicaid is the primary, the ordering, referring and prescribing requirement
applies and pharmacy claims will deny if the prescriber isn’t enrolled. These provisions also apply to clients participating in the Texas Dual Eligible Integrated Care Project and who are enrolled into a Medicare-Medicaid Plan.