Who must complete a new enrollment form?

Providers wanting to participate in the Children with Special Health Care Needs (CSHCN) Services Program must complete an enrollment application. Providers of medical services must be actively enrolled as a Texas Medicaid provider as a prerequisite to becoming a CSHCN Services Program provider. This requirement is waived for providers of non-medical program services such as family support providers, funeral homes, meals, lodging, or transportation providers.

A new CSHCN Services Program Provider Enrollment Application must be completed whenever a provider is required to reapply to the Texas Medicaid Program because of a change to the following:

·         Medicare Number

·         Ownership

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

·         Provider Type

 

Required Enrollment Forms 

Providers seeking enrollment in the CSHCN Services Program must complete the following forms:

 

Children with Special Health Care Needs (CSHCN) Services Program Provider Enrollment Application. The application includes: CSHCN Services Program Identification Form Provider Agreement with DSHS for Participation in the CSHCN Services Program Certification Regarding Debarment Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts	All providers
Provider Information Form (PIF-1)	All providers applying for CSHCN Services Program enrollment more than one year from their Texas Medicaid enrollment date.
Principal Information Form (PIF-2)	Each principal of all providers applying for CSHCN Services Program enrollment more than one year from their Texas Medicaid enrollment date.
Disclosure of Ownership Form	All providers applying for CSHCN Services Program enrollment more than one year from their Texas Medicaid enrollment date.
W-9 Request for Taxpayer Identification Number and Certification	All providers
Required Information for Dental/Orthodontia Providers Only	Dental and orthodontic providers
Required Information for Stem Cell Transplant Facility Providers Only	Stem cell transplant facilities
Required Information for Physician and Dentist Providers of Cleft/Craniofacial Surgical Services Only	Providers requesting enrollment as a comprehensive cleft/craniofacial team
Required Information for Affilliated Provder of Cleft/Craniofacial Team	Providers affiliated with a CSHCN Services Program-enrolled cleft/craniofacial team
Required Information for Customized Durable Medical Equipment (DME) providers	Providers of customized DME

 

Chapter 3 of the 2008 CSHCN Services Program Provider Manual includes details of the enrollment process. 

The Enrollment Process

For assistance with the application process, call the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413, Option 2. Retain a copy of the original application for future reference.

After completing the enrollment application providers should send it and the supporting documentation to the following address:

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

Applicants 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. To prevent unnecessary delays in the enrollment process, applicants should thoroughly review their enrollment application for accuracy and completeness before submitting it to TMHP.