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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.4 Claims Filing Instructions : 6.4.2 Claim Form Requirements : 6.4.2.4 Ordering or Referring Provider NPI

6.4.2.4
All Texas Medicaid claims for services that require a physician order or referral must include the ordering or referring provider’s NPI:
If the ordering or referring provider is enrolled in Texas Medicaid as a billing or performing provider, the billing or performing provider NPI must be used on the claim as the ordering or referring provider.
If the ordering or referring provider is not currently enrolled in Texas Medicaid as a billing or performing provider, the provider must enroll to receive an ordering or referring-only TPI. After the ordering or referring provider is enrolled, the ordering or referring provider’s NPI must be used on the claim as the ordering or referring provider.
Important:
Claims that are submitted without the ordering or referring provider’s NPI and claims submitted with an NPI for a provider who is not enrolled in Texas Medicaid may be subject to retrospective review and denial for a missing or invalid NPI.
Note:
Providers who enroll in Texas Medicaid as ordering- and referring-only providers receive a TPI that can be used for orders and referrals for Texas Medicaid clients and CSHCN Services Program clients.

Texas Medicaid & Healthcare Partnership
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