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 and paper prior authorization requests or for calling TMHP. The TPI fields have been removed from prior authorization forms, instructions, and consent forms.
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 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.
Providers Must Stop Using TPIs by December 1, 2021
Effective December 1, 2021, forms with TPIs will be returned, resulting in a delay in authorization approval or service reimbursement.
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.
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:
- F00001: Outpatient Withdrawal Management Authorization Request Form
- F00002: Outpatient Substance Use Disorder Counseling Extension Request Form
- F00011: CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services
- F00012: CCP Prior Authorization Form Request
- F00012: CCP Prior Authorization Form Instructions
- F00014: CRCP Prior Authorization Request Form
- F00017: THSteps Dental Mandatory Prior Authorization Request Form
- F00018: DME Certification and Receipt Form
- F00020: Donor Human Milk Request Form
- F00024: External Insulin Pump Prior Authorization Form
- F00028: Home Health Plan of Care (POC)
- F00028: Home Health Plan of Care (POC) Instructions
- F00030: Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form
- F00030: Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions
- F00031: Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form
- F00032: Home Telemonitoring Services Prior Authorization Request Texas Medicaid
- F00032: Home Telemonitoring Services Prior Authorization Request Form Instructions
- F00040: Medicaid Certificate of Medical Necessity for Reduction Mammaplasty
- F00044: Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program Non-emergency Ambulance Exception
- F00045: Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program Non-emergency Ambulance Prior Authorization Request
- F00046: Obstetric Ultrasound Prior Authorization Request Texas Medicaid Program
- F00046: Obstetric Ultrasound Prior Authorization Request Instructions
- F00070: CCP Prior Authorization Private Duty Nursing 6-Month Authorization
- F00074: Psychiatric Inpatient Extended Stay Request Form
- F00084: Residential Withdrawal Management Authorization Request Form
- F00085: Residential Substance Use Disorder Treatment Request Form
- F00087: Special Medical Prior Authorization (SMPA) Request Form
- F00090: Sterilization Consent Form (English)
- F00090: Sterilization Consent Form (Spanish)
- F00090: Sterilization Consent Form Instructions
- F00098: Wheelchair/Scooter/Stroller Seating Assessment Form
- F00120: Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers
- F00122: Prescribed Pediatric Extended Care Center (PPECC) Plan of Care
- F00122: Prescribed Pediatric Extended Care Center (PPECC) Plan of Care Instructions
- F00136: Hereditary Breast and Ovarian Cancer (HBOC) Genetic Testing Prior Authorization Form and Instructions
- F00139: Texas Medicaid Physical, Occupational, or Speech Therapy (PT, OT, ST) Prior Authorization Form
- F00139: Texas Medicaid Physical, Occupational, or Speech Therapy (PT, OT, ST) Prior Authorization Form Instructions
- F00143: Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program Handicapping Labio-Lingual Deviation (HLD) Index Score Sheet
- F00144: Texas Medicaid Prior Authorization Request for Oxygen Therapy Devices and Supplies
- F00145: Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices – Initial Request
- F00146: Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices – Renewal Request
- F00147: Texas Medicaid Prior Authorization Request for CPAP or RAD (Bi-level PAP)
- F00153: Outpatient Mental Health Services Request Form
- F00164: Wound Care Equipment and Supplies Order Form
For more information, call the TMHP Contact Center at 800-925-9126.