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.
Effective September 1, 2021, providers are no longer required to use their Texas Provider Identifiers (TPIs) for submitting paper claims, paper prior authorization requests, or for calling TMHP. The TPI fields have been removed from claim forms, electronic data interchange (EDI) forms, and instructions.
Providers Must Use Their NPIs Effective September 1, 2021
In place of TPIs, providers must submit their National Provider Identifiers (NPIs) and related data on forms. Providers or individuals who do not provide health-care services and who are not required to have NPIs may have been issued Atypical Provider Identifiers (APIs). These providers should use their APIs instead of the TPIs.
Using the NPI will save time and simplify administrative work for health-care providers:
- The NPI is a single provider identification number that will be recognized and accepted by all health plans.
- Providers will no longer need to report, maintain, or track multiple provider identification numbers; this will improve the efficiency and effectiveness of electronic health-care transactions.
To promote a smooth transition as TPIs are phased out, TMHP will continue to accept older forms that include TPIs after September 1, 2021, until November 30, 2021. After this transition period ends, only the revised NPI/API-based forms will be accepted.
Effective December 1, 2021, forms with TPIs will be returned, resulting in a delay in authorization approval or service reimbursement.
Providers Must Stop Using TPIs by December 1, 2021
In place of TPIs, providers will need to submit their NPI/API, taxonomy code, benefit code (if applicable), and complete address with city, state, and ZIP+4 code. To avoid any claims processing errors, providers should complete their claims with the same information that was included on the prior authorization request.
The following forms and instructions have been revised and updated, and the forms will be available on September 1, 2021, as fillable PDFs on tmhp.com under “Forms,” and on TMHP’s Prior Authorization on the Portal:
- F00013: Claim Status Inquiry Authorization
- F00023: Electronic Remittance Agreement Form and Instructions
- F00025: 2017 Claim Form – Family Planning
- F00035: Informational Claims Submission Form
- F00041: Medicare Advantage Plan (MAP) Crossover Professional Claim Type 30 Template
- F00042: MAP Crossover Outpatient Facility Claim Type 31 Template
- F00043: MAP Crossover Inpatient Hospital Claim Type 50 Template
- F00079: Texas Medicaid Refund Information Form
- F00154: TMHP Portal Request Change Form
- Electronic Data Interchange Trading Partner Agreement
- Centers for Medicare & Medicaid Services (CMS)-1500: Refer to the instructions in the Texas Medicaid Provider Procedures Manual (TMPPM).
- CMS UB-04: Refer to the instructions in the TMPPM.
- American Dental Association (ADA) Dental Forms 2018/2019: Refer to the instructions in the TMPPM.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.