Current CHIP Providers Must Complete Enrollment with TMHP by December 31, 2017 to Continue to Receive Reimbursement for Services

Note: The Health and Human Services Commission (HHSC) has requested that TMHP publish the following information:

Federal law and regulation require states to screen and enroll all network providers including Children’s Health Insurance Program (CHIP) providers by December 31, 2017. To meet this requirement and continue receiving reimbursement for services, providers who currently render services to CHIP members through a managed care organization (MCO) must complete enrollment with the Texas Medicaid & Healthcare Partnership (TMHP) by December 31, 2017.

While the enrollment process and application are the same for Medicaid and CHIP providers, CHIP-only providers are not required to participate in Texas Medicaid. CHIP-only providers must follow the instructions below to indicate they intend to serve only CHIP members and to ensure that they do not appear on the Medicaid online provider lookup (OPL).

Note: CHIP providers actively enrolled with TMHP as a Medicaid provider do not need to repeat the enrollment process to continue to receive reimbursement for CHIP services.

Enrollment Information Specific to CHIP Providers

Beginning July 1, 2017, providers can indicate in the enrollment application that they intend to serve only CHIP members. Providers must document this appropriately to ensure they are not displayed as a Medicaid provider on OPL. CHIP providers are encouraged to enroll using the Provider Enrollment on the Portal (PEP). Additionally, the Provider Information Management System (PIMS) will be updated with options for providers to designate that they intend to serve only CHIP members.

Providers should begin the enrollment process as soon as possible. The PIMS update will allow providers who start the enrollment process before these updates occur to designate themselves as CHIP-only providers on the OPL after they are enrolled.

For more information, providers should visit the upcoming CHIP webpage that will be added to in the next few weeks.

For more information, call the TMHP Contact Center at 1-800-925-9126.

Medicaid Ordering/Referring Provider Enrollment Requirement

Federal regulation 42 CFR §455.410 indicates that a state Medicaid agency must require all ordering, referring or prescribing physicians or other professionals providing services under the state plan or under a waiver of the state plan to be enrolled as participating providers.

For providers whose only relationship with Texas Medicaid is to order or refer services for Texas Medicaid clients, TMHP has developed an abbreviated enrollment application titled “Texas Medicaid Provider Enrollment Application Ordering and Referring Providers Only.” This shortened application allows providers to enroll as an ordering or referring provider without participating as a rendering or billing provider within the state Medicaid program.

Medicaid clients who attempt to obtain prescription drugs using a prescription from a non-enrolled provider will be unable to obtain their prescribed medications starting October 16, 2017.

Important: Claims for items or services ordered, referred, or prescribed by interns or residents may include the NPI of a supervising physician.

Note: Individual providers enrolled in Medicaid as a rendering or billing provider can use their existing NPI for orders, referrals and prescriptions. Providers do not need to submit the additional abbreviated application. Individual providers employed by a facility, organization, federally qualified health center (FQHC) or rural health clinic (RHC) which is enrolled in Medicaid will need to complete the abbreviated application to order, refer, or prescribe services for their clients.

Note: This claims edit is not applicable to Medicare crossover claims. Providers who order, refer, or prescribe Medicare covered services for dual eligible clients will not need to enroll in Medicaid. However, Medicaid only services ordered, referred, or prescribed will require the ordering provider to be enrolled in Medicaid.

An Ordering/Referring Provider Frequently Asked Questions (FAQ) document is being developed and will be available on the TMHP website in the near future.

For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.

If you have any questions please contact our Provider Relations Team at 1-915-532-3778 x1507 Monday – Friday 8am – 5pm.