Observation Stays No Longer Subject to Concurrent Review

Medicaid/CHIP—Delayed Implementation for Required Enrollment of All Ordering, Referring or Prescribing Providers

Wednesday, September 6, 2017

Background:
On July 15, 2016, Texas Medicaid announced changes to claims for payment requirements. Claims for payment must include the National Provider Identifier of the physician or other professional who ordered, referred or prescribed the items or services (Code of Federal Regulations Title 42, Section 455.440). The physician or other professional identified on the claim must be enrolled as a participating provider in Medicaid, including for claims for prescription drugs dispensed at a pharmacy (Code of Federal Regulations Title 42, Section 455.410).

On June 2, 2017, Texas Medicaid notified stakeholders that beginning Oct. 1, 2017, HHS would deny claims for items and services ordered, referred or prescribed by a provider not enrolled in Texas Medicaid for the Medicaid, Children with Special Health Care Needs Services Program and Healthy Texas Women programs.

UPDATE:
Due to the impact of Hurricane Harvey and pending decisions that may impact the implementation of the Federal Regulation, HHS is delaying the deployment of this requirement. All medical and pharmacy claims will continue to pay through calendar year 2017 regardless of the ordering, referring, or prescribing provider's Texas Medicaid enrollment status. HHS will begin enforcing the enrollment requirement in January 2018 for Medicaid, Children's Health Insurance Program (CHIP), CSHCN Services Program and Healthy Texas Women. HHS will provide specific dates and details in the coming weeks. If possible, ordering, referring, and prescribing providers should begin the enrollment process before January by completing the application online at: http://www.tmhp.com/Pages/ProviderEnrollment/PE_TX_Medicaid_New.aspx

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