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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.12 Filing Medicare Primary Claims : 6.12.1 Electronic Crossover Claims : Requirement for Group Billing Providers – Professional Claims
The performing provider NPI must be included on the professional electronic claim if the billing provider is a group. Claims are processed using the performing provider NPI that is submitted on the Medicare claim.
The performing provider who is identified on the claim must be a member of the billing provider’s group. If the performing provider is not a member of the billing provider group, the detail line item will be denied.
A claim is denied if the performing provider NPI is missing, invalid, or is not a member of the billing provider’s group. Denied claims may be appealed on paper with the appropriate performing provider information.

Texas Medicaid & Healthcare Partnership
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