To receive payment for claims, PCCM providers must be listed as the primary care provider on the Medicaid ID Form (H3087) with two exceptions:

·         The client's H3087 does not list any primary care provider’s name.

·         The services rendered are exempt from the referral process. Services exempt from referrals are OB/GYN services, THSteps medical and dental services, eye care, family planning, mental health and substance abuse services, and 24-hour emergency room care.

For all other services, the treating provider must obtain a referral from the designated primary care provider. Providers who are unable to obtain a referral from a client’s primary care provider should contact the PCCM Provider Helpline at 1-888-834-7226, Monday through Friday, 7 a.m. until 7 p.m., Central Time.

Primary care providers must supply their Texas Provider Identifiers (TPIs) to specialists to ensure that claims are processed appropriately. Claims with invalid or missing referring provider identifiers will be denied. The referring physician’s TPI should be in Block 17a of the CMS-1500 claim form or in Blocks 78 and 79 of the UB-04 CMS-1450 claim form. Details of the claim form information can be found in the 2007 National Provider Identifier (NPI) Special Bulletin, No. 202.

Primary care providers may allow clients to call from their offices to change primary care providers. As many as ten clients can request a primary care provider change from each call initiated at a provider’s office. The PCCM Client Helpline number is 1-888-302-6688, available Monday through Friday, 7 a.m. until 7 p.m., Central Time.

For more information, call the PCCM Provider Helpline at 1-888-834-7226 or the TMHP Contact Center at 1-800-925-9126.