The Top 5 reasons Medicaid Provider Enrollment applications are returned:

1. The legal name listed on the top line of the IRS W-9 form is not identical to the legal name on pages 7.1 and 11.1 of the completed application.
2. The Provider Information Form has not been completed for each practitioner, individual, or group associated with the application.
3. The Provider Agreement has not been completed for each practitioner, individual, or group associated with the application.
4. A photocopy of the provider's current license has not been provided. The license must not expire within 30 days of receipt of the completed application.
5. Page 9.4 has not been completed correctly. Page 9-4 requires information and certification by a Notary Public.

Reminders:

1. Applications are available from TMHP through this website and can be easily printed on a local printer. Field editing features prompt the applicant to complete all required fields and correct inaccurate information to ensure the application is complete prior to printing and mailing the application to the TMHP Provider Enrollment Department. Accessing information via the website will eliminate the wait time to receive an application through the mail.
2. When calling TMHP to check the status of a Medicaid provider enrollment application, please have name (as it appeared on the application) and Tax ID number or Social Security Number ready for the customer service representative.
3. Providers who call TMHP to change their provider status will also be required to complete and submit a Provider Information Change Form. This form requires the provider's signature, 9-digit Medicaid TPI number, and an IRS W-9 form when changing a mailing address, Tax ID number, or legal name.