October 2017

HHSC Notice: Prescriber Enrollment Project Cancelled; No Longer Applies to Managed Care Out-of-Network Providers

The Texas Health and Human Services (HHSC) recently obtained clarification from the Centers for Medicare & Medicaid Services (CMS) that 42 CFR 455.410(b) is not applicable to out-of-network providers serving managed care clients.

Any provider who orders, refers or prescribes drugs or services for a traditional Medicaid client is subject to 42 CFR 455.410(b) and must be enrolled in the Texas Medicaid & Healthcare Partnership (TMHP). However, out-of-network providers who order, refer or prescribe only for managed care enrollees are not required to enroll with TMHP.

HHSC previously directed managed care organizations (MCO) to reach out to non-enrolled prescribers and affected members to inform them of the requirements set forth in 42 CFR 455.410(b). Based on this new direction from the CMS, MCOs should cease all such communications to providers and members. MCOs should also make sure all provider manuals and member handbooks are updated to reflect this new direction.

MCOs must not at any time deny pharmacy or medical claims because the ordering, referring or prescribing provider is not enrolled with TMHP.