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Provider Enrollment and Responsibilities
1.1 Provider Enrollment 1-3
1.1.1 TMHP Provider Enrollment 1-3
1.1.2 Provider Enrollment Application Determinations 1-5
1.1.3 Enrollment in Medicaid Managed Care Programs 1-5
1.1.4 Required Enrollment Forms 1-6
1.1.4.1 Texas Medicaid Provider Enrollment Application 1-6
1.1.4.2 HHSC Medicaid Provider Agreement 1-6
1.1.4.3 Provider and Principal Information Forms 1-6
1.1.4.4 Disclosure of Ownership and Control Interest Statement 1-6
1.1.4.5 Internal Revenue Service (IRS) W-9 Form 1-7
1.1.4.6 Medicaid Audit Information Form 1-7
1.1.4.7 Corporate Board of Directors Resolution 1-7
1.1.4.8 Certificate of Good Standing (Board Corporation Act, Article 2.45) 1-7
1.1.4.9 Certificate of Formation or Certificate of Filing/Certificate of Incorporation 1-7
1.1.4.10 Certificate of Authority 1-7
1.1.4.11 Copy of License/Temporary License/Certification 1-7
1.1.4.12 Licensure Renewal 1-7
1.1.4.13 Medicare Participation 1-8
1.1.4.14 Group Information Changes 1-8
1.2 Payment Information 1-8
1.2.1 Using EFT 1-8
1.2.2 Advantages of EFT 1-8
1.2.3 EFT Enrollment Procedures 1-8
1.2.4 Stale-Dated Checks 1-9
1.3 Provider Reenrollment 1-9
1.4 Provider Responsibilities 1-9
1.4.1 Compliance with Texas Family Code 1-9
1.4.1.1 Child Support 1-9
1.4.1.2 Reporting Child Abuse or Neglect 1-10
1.4.1.3 Procedures for Reporting Abuse or Neglect 1-10
1.4.1.4 Procedures for Reporting Suspected Sexual Abuse 1-10
1.4.2 Maintenance of Provider Information 1-11
1.4.2.1 NPI Verification 1-11
1.4.2.2 Online Provider Lookup 1-11
1.4.3 Retention of Records and Access to Records and Premises 1-12
1.4.3.1 Payment Error Rate Measurement (PERM) Process 1-13
1.4.4 Release of Confidential Information 1-13
1.4.5 Compliance with Federal Legislation 1-13
1.4.6 Tamper-Resistant Prescription Pads 1-14
1.4.7 Utilization Control - General Provisions 1-14
1.4.8 Provider Certification/Assignment 1-15
1.4.8.1 Delegation of Signature Authority 1-15
1.4.9 Billing Clients 1-16
1.4.9.1 Client Acknowledgment Statement 1-16
1.4.10 General Medical Record Documentation Requirements 1-17
1.4.11 Informing Pregnant Clients About CHIP Benefits 1-18
1.5 Medicare/Medicaid Waste, Abuse, and Fraud Policy 1-18
1.5.1 Reporting Waste, Abuse, and Fraud 1-24
1.5.2 Suspected Cases of Provider Waste, Abuse, and Fraud 1-24
1.5.3 Employee Education on False Claims Recovery 1-25
1.6 Texas Medicaid Limitations and Exclusions 1-25
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