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Reminder: Provider Information Validation on LTC Claims Began June 10, 2022

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Provider information on long-term care (LTC) claims will be validated using data stored in the National Plan and Provider Enumeration System (NPPES) and the TMHP Provider Enrollment and Management System (PEMS). This enhancement will ensure consistency of provider information and help avoid claim rejection. Attending provider information will be validated on nursing facility and ICF claims. Referring provider information will be validated on hospice claims. 

The following data will be validated for attending and referring providers:

  • National Provider Identifier (NPI)
  • Dates of service on the claim, which must be within the Texas Medicaid enrollment period(s)
  • Provider type qualifier
  • First and last name

Effective October 1, 2022, claims with invalid attending and referring provider information will be rejected.

The provider must be enrolled in Texas Medicaid; otherwise, LTC claims could be denied or rejected due to a mismatch in the claim information. The mismatches may cause submitted claims to be assigned one of the explanations of benefits (EOBs) in the following table:

EOB

EOB Description

V2254

Header Attending NPI is not enrolled in Texas Medicaid.

V2255

Header Attending Provider Entity type is invalid.

V2256

Header Attending Provider Last Name does not match the Last Name on file for the NPI.

V2257

Header Attending Provider First Name does not match the First Name on file for the NPI.

V2258

Header Referring NPI is not enrolled in Texas Medicaid.

V2259

Header Referring Provider Entity Type is invalid.

V2260

Header Referring Provider Last Name does not match the Last Name on file for the NPI.

V2261

Header Referring Provider First Name does not match the First Name on file for the NPI.

For more information about using PEMS, providers can refer to the article “TMHP Provider Enrollment and Management System (PEMS) Training Materials Available” and Section 352.5 of the Texas Administrative Code. For more information, contact the LTC Help Desk at 800-626-4117.