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1.1.5.13 Medicare Participation
Under federal law, Medicaid is the payor of last resort, so Medicare-covered services must first be billed to and paid by Medicare. Therefore, in order to be eligible to enroll in Texas Medicaid, a provider must be a Medicare participating provider. Certain types of providers, however, are not required to meet the Medicare participation requirement, including:
• OB/GYN providers
•Pediatric providers
•Family Planning providers
•Case Management for Children and Pregnant Women (CPW) program providers
•Comprehensive Care Program (CCP) providers
•Licensed professional counselors (LPCs)
•Licensed marriage and family therapists (LMFTs)
Some provider types may apply for a waiver of the Medicare certification requirement of the application process if they do not serve Medicaid-eligible individuals. The following provider types are eligible to apply for this waiver:
•Ambulatory Surgical Center (ASC)
•Audiologist
•Certified Nurse Midwife (CNM)
•Certified Registered Nurse Anesthetist (CRNA)
•Chiropractor
•Dentist (D.D.S. or D.M.D.)
•Durable Medical Equipment (DME)
•Independent Lab (No physician involvement)
•Independent Lab (Physician involvement)
•Nurse Practitioner/Clinical Nurse Specialist (NP/CNS)
•Optometrist (OD)
•Physician (DO)
•Physician (MD)
•Physician Assistant (PA)
•Podiatrist
Each provider seeking enrollment must include a valid and current Medicare number in the Texas Medicaid Provider Enrollment Application, and must include with the application a copy of the provider's notice of Medicare participation.
Each group and each performing provider of a Medicare group must have a current Medicare number. The group enrollment application must include the current and valid Medicare number for the group and for each performing provider in the group, as well as a copy of the notice of Medicare enrollment for the group and for each performing provider in the group.
Each group enrolling as a Medicaid-only does not need to submit a current Medicare number for the group. Performing providers added to this Medicaid-only group also do not require a current Medicare number.
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