June 25, 2014

State of Alabama
Press Release: Medicaid

Patient 1st Clarification to ALERT dated April 29th Related to PMP Referrals

TO:     All Physicians and enrolled Patient 1st Providers


Below is a list of frequently asked questions (FAQ) and definitions which should clarify the ALERT sent to providers on April 29, 2014 regarding ‘Change to use of Group NPI and Non-enrolled Physicians in the Patient 1st Program. 



Definition of Referring Provider:  The provider who is making the referral to a specialist and who has seen the patient. This provider MUST be enrolled as a Patient 1st Provider.


Definition of PMP:  Primary Medical Provider that the patient is assigned to per the Medicaid Web Portal. This can be an Individual or a Group.


For Billing Purposes Only:  The Patient 1st provider in a group whose Individual NPI is given by that group to use as the Billing NPI. The Patient 1st provider may not have seen this patient but the patient was assigned to that group. The Individual NPI should have been submitted to Provider Enrollment to link to the Group to which the patient is assigned.


Frequently Asked Questions:


1.         With the new change, what name and NPI should be on the referral form? 


Medicaid’s Response:  The name and Individual NPI of the referring Patient 1st provider must be on the referral form. 


2.         What name and NPI should be on the referral form if the patient is assigned to a Group?


Medicaid’s Response:  The name and Individual NPI of the referring Patient 1st provider should be on the referral form.  


3.         We are getting referrals from primary care physician groups and many of them are not signed by the assigned PMP.  Please describe how we are to bill the claim to HP for processing?


Medicaid’s Response:  The referral must be signed by the referring Patient 1st provider or their designee.   Please remember to use the full name and not initials on the referral. 


In order for the specialist’s claim to process, the name and Individual NPI of the referring Patient 1st provider must be on the claim.   


4.         Physicians are in the same group, a doctor in the group goes to another site to fill in for another physician (on vacation, out on sick leave, etc.).  Can the physician filling in make the referrals on behalf of the physician they are filling in for? 


Medicaid Response:  The referring provider who is filling in for the primary PMP must be enrolled as a Patient 1st provider and make sure that his/her Individual NPI is used in making the referral. The primary PMP’s number should not be on the referral since the primary PMP did not make the referral.


5.        A recipient is assigned to a group. No physician in the group has treated the patient. A PMP change has been completed, but is not yet effective. The new PMP has requested a ‘billing only’ referral, but does not know which physician NPI to put on the form because none of the providers has rendered services to the recipient. Which NPI should the provider use on the ‘billing only’ referral?


Medicaid’s Response:  The new PMP should contact the assigned Group and ask for a Patient 1st PMP on file to use for the ‘billing only’ referral. This can be any Individual NPI attached to the Group but must be given to the new Patient 1st PMP by the currently assigned Group.


6.a.  How will a provider in a group (with group information on eligibility printout) know which patients are assigned to him under Patient 1st? 


Medicaid’s Response:  PMP assignment is determined within the Group, Medicaid does not make individual assignment of a recipient within a Group.


6.b.   In other words, how will they know which provider in the group should be on a referral? 


Medicaid’s Response:  The name and NPI of the referring Patient 1st provider must be on the referral form.


7.         We have a referral from the Group that is valid for one year. Do we have to get a new referral or can we call and get the name and Individual NPI of the PMP that saw the patient that day? Is there a risk of recoupment if we do not get a new referral?


Medicaid’s Response:  The referral is still valid, a new one is not necessary.  Contact the Group and obtain the referring Patient 1st provider’s Name and Individual NPI and document this information on the referral. There is no risk of recoupment in this situation.


8.         How will the specialist or the provider receiving the referral know if the physician making the referral is Patient 1st?  What steps does the specialist take if the referring physician is not Patient 1st?


Medicaid’s Response:  A non- Patient 1st provider should not be referring to a specialist, unless it is a cascading referral. Please see answer to question # 9 below for more information on cascading referrals.


9.         How does a specialist handle cascading referrals and claims? Will cascading referrals be allowed?


Medicaid Response:  A specialist may refer to another specialist on a cascading referral as long as the referring Patient 1st provider has received documentation that this has occurred.  All specialists should be communicating with the referring Patient 1st PMP to ensure proper case management has occurred. 


In order for any specialist’s claims to process, the NPI of the referring Patient 1st provider must be on the claim.


10.      What are the steps for a specialist to take if a provider has received a valid referral under a Group NPI and has called the Group to request the NPI of the individual provider and the Group refuses to provide the information?


Medicaid Response:  Notify an HP Provider Representative when this occurs.  Phone numbers may be obtained on the following link:     



11.       How will adding the physicians as Patient 1st to the group change the panel numbers? For example:  Will this affect panel size? 


Medicaid Response:  The number of physicians/extenders has to support the panel size of the Group.


12.      Should my specialty practice refuse to treat Medicaid recipients assigned to a Group PMP if we cannot verify the individual’s NPI?


Medicaid Response:  A specialty provider should not refuse to treat a recipient if  a valid referral has been received.  When this occurs, notify an HP Provider Representative.  Phone numbers may be obtained on the following link:



13.       A recipient is assigned to a group, and the Nurse Practitioner or Physician Assistant sees the patient, whose NPI should be on the referral? 


Medicaid Response:  The NP or PA should have an agreement with the collaborating physician. The collaborating physician’s name and NPI must be on the referral. The NP or PA’s name and number should also be included on the referral form with a note that consultant information should be sent to the NP or PA who referred the patient. The referral form should be signed by the NP or PA who made the referral.


For payment purposes:  If the NP or PA provides care, their NPI must be on the claim form as the rendering provider.


14.      Will prior authorizations deny without the PMP’s NPI listed on the referral form? 


Medicaid’s Response:  The group NPI number will no longer be recognized for referrals. This means the referring provider number on the referral and claim must be the NPI of the referring physician, not the NPI of the group. A group NPI number will cause a Prior Authorization (PA) and the claim to deny.


15.      How does my Group practice enroll our Patient 1st PMP’s within the Group? 


Medicaid Response:  Individual Providers in a Group:

Individual providers within a PMP enrolled group may update the Group/Clinic Patient 1st Update Form and fax to Provider Enrollment at 334-215-4298. This form is located on the following link:


This will ensure a smooth enrollment of an individual PMP within a group.

16.      Explain how claims with dates of service prior to June 3, 2014, will process? 


Medicaid Response:  A system change was made on Wednesday, June 25, 2014, to allow claims with dates of service on or before June 3, 2014, to continue to use the group NPI. 


The Alabama Medicaid Agency will identify and reprocess any claims that denied for the group NPI if the following criteria are met:

·            Claims were received between June 3, 2014 and June 24, 2014

·            Claims dates of service were prior to June 3, 2014


  • For more information, visit http://medicaid.alabama.gov
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