Who must complete a new enrollment form?

A provider who wants to become a Medicaid provider must complete a new enrollment application. Generally speaking, a provider must first be a Medicare provider before becoming a Medicaid provider. This requirement can be waived for pediatric providers that would never bill Medicare claims.

A new enrollment application must also be completed and a new provider identifier must be issued when one of the following changes:

·         Medicare Number

·         Ownership

·         Provider Status (individual, group, performing provider, or facility)

·         Provider Type

The Enrollment Process

The Texas Medicaid Provider Enrollment Application packet is available online. Providers can download and print the application and then complete it. Providers can call the TMHP Contact Center at 1-800-925-9126, Option 2, for help with completing the application. Providers should retain a copy of the original application for future reference.

After completing the enrollment application, providers should send it, along with supporting documentation, to the following address:

Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795

Providers will be notified of incomplete applications and will have 30 business days to provide the requested missing information. If the information is not provided within 30 business days, TMHP will terminate the enrollment process and a new enrollment application must be submitted. Providers are required to review their enrollment application for accuracy and completeness before submitting it to TMHP.

Required Enrollment Forms

Providers should refer to the 2008 Texas Medicaid Provider Procedures Manual, section 1.1.3 entitled “Required Enrollment Forms” starting on page 1-2 for details of these requirements.

The following forms are required to enroll in the Texas Medicaid Program and, except where noted, are included in the Texas Medicaid Provider Enrollment Application packet.

Form	Applies to
Texas Medicaid Provider Enrollment Application	All providers
HHSC Medicaid Provider Agreement	All providers
Provider Information Form (PIF-1)	All providers
Principal Information Form (PIF-2)	Each principal of all providers
Medicare Confirmation Letter (not part of enrollment packet)	All providers who are also Medicare providers
Disclosure of Ownership and Control Interest Statement	All providers, except the performing providers of a group
Internal Revenue Service (IRS) Form W-9	All providers, except the performing providers of a group
Medicaid Audit Information Form	Facil­ities such as hospitals, home health agencies, federally qualified health centers, rural health clinics, and dialysis facilities
Corporate Board of Directors Resolution	All providers that are corporations
Certificate of Good Standing (Board Corpo­ration Act, Article 2.45) (Enrollment packets includes directions for obtaining this certificate.)	All corporations that are not exempt from Franchise Tax
Certificate of Formation or Certificate of Filing (not included in enrollment packet)	All in-state corporate providers
Certificate of Authority (not included in enrollment packet)	All out-of-state corporate providers
Copy of License/Temporary License/Certification (not included in enrollment packet)	All licensed or certified professionals except as noted