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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.1 Provider Enrollment and Reenrollment : 1.1.4 Provider Enrollment Identification : 1.1.4.1 Ordering- or Referring-Only Providers

1.1.4.1
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. This requirement is in accordance with provisions of the Affordable Care Act of 2010 (ACA), 42 CFR §455.410(b), which 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.
These providers can enroll online using the PEP tool by clicking the check box for Ordering/Referring Provider, or they can use the streamlined paper Texas Medicaid Provider Enrollment Application Ordering and Referring Providers Only, which is available for download on the TMHP website at www.tmhp.com.
The ordering or referring-only enrollment application is for individual providers who are not currently enrolled as a billing or performing provider in Texas Medicaid or the CSHCN Services Program and who do not currently have an active Texas Medicaid or CSHCN Services Program billing provider Texas Provider Identifier (TPI).
Important:
Individual providers who are currently enrolled in Texas Medicaid or the CSHCN Services Program and who currently have an active Texas Medicaid or CSHCN Services Program billing provider TPI can use their current TPI for ordering/referring services and do not need to obtain an ordering/referring TPI. A current provider’s active TPI will be deactivated if the provider enrolls as an ordering or referring-only provider.
Providers who enroll in Texas Medicaid as ordering- and referring-only providers receive one TPI that can be used for orders and referrals for both Texas Medicaid clients and CSHCN Services Program clients. Although ordering- and referring-only providers do not submit claims to TMHP for rendered services, the ordering or referring provider’s NPI is required on claims that are submitted by the providers that render the supplies or services.
Refer to:
Subsection 6.4.2.4, “Ordering or Referring Provider NPI” in “Section 6: Claims Filing” (Vol. 1, General Information) for information about filing claims that require an ordering- and referring-only provider NPI.

Texas Medicaid & Healthcare Partnership
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