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Update Regarding Attending Provider NPI Requirements for Outpatient Claim Submissions

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Beginning November 1, 2019, TMHP will update the Texas Medicaid Provider Procedures Manual, Claims Filing Handbook, to add language regarding Attending Provider National Provider Identifier (NPI) requirements. In addition, TMHP will update block 76 of the UB-04 CMS-1450 Instruction table to require attending provider information for outpatient claims.

The following language will be added:

The attending provider is the individual who would normally be expected to certify and re-certify the medical necessity of the number of services rendered or who has primary responsibility for the patient's medical care and treatment.

Note: Outpatient claim providers may be instructed to submit the ordering provider name and NPI number in the attending provider field.

For more information, call the TMHP Contact Center at 800-925-9126.