2.1.4 Provider Enrollment Determinations

The CSHCN Services Program may approve, deny, modify, suspend, or terminate a provider’s enrollment for the reasons listed in the Texas Administrative Code (TAC), CSHCN Services Program Rules 25§38.6(b)(1) through (2) at www.sos.state.tx.us/tac. Before taking action to deny, modify, suspend, or terminate enrollment, the CSHCN Services Program shall give the provider written notice of an opportunity to request an administrative review of the proposed action within 30 days of the notice. If the provider does not respond in writing within the 30-day period, the provider is presumed to have waived the administrative review as well as access to a fair hearing, and the CSHCN Services Program’s action is final. If the provider so requests, the CSHCN Services Program will conduct an administrative review of the circumstances of the proposed denial, modification, suspension, or termination of provider program participation is based and give the provider written notice of the program decision and the supporting reasons within 30 days of receipt of the request for administrative review.

In addition, a fair hearing is available to any provider for the resolution of conflict between the CSHCN Services Program and the provider if the fair hearing is requested within 20 days of receipt of the administrative review decision.

Refer to:

Chapter 7, “Appeals and Administrative Review,” on page 7-1.

Providers excluded or terminated by Medicaid will be excluded or terminated by the CSHCN Services Program.

Providers must maintain active enrollment in Medicaid to remain enrolled in the CSHCN Services Program. “Actively enrolled” providers are those that have filed claims for clients of the CSHCN Services Program or Texas Medicaid within the past 24 months, and that do not have any type of payment holds on their enrollment status.

Descriptions of required enrollment forms are provided in the following sections. Forms are available on the TMHP website at www.tmhp.com.