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1.1 Provider Enrollment
1.1.1 TMHP Provider Enrollment
The National Provider Identifier (NPI) final rule, Federal Register 45, Code of Federal Regulations (CFR) Part 162, established the NPI as the standard unique identifier for health-care providers and requires covered health-care providers, clearinghouses, and health plans to use this identifier in Health Insurance Portability and Accountability Act (HIPAA)-covered transactions. An NPI is a 10-digit number assigned randomly by the National Plan and Provider Enumeration System (NPPES).
Initial Texas Medicaid fee-for-service enrollment and reenrollment can be completed online. This includes the Texas Health Steps (THSteps) program for both medical and dental providers and case management for Children and Pregnant Women (CPW). A link to the provider enrollment application is provided on the TMHP website homepage at www.tmhp.com.
Online enrollment has the following advantages:
• Applications are validated immediately to ensure that all fields have been completed.
•Most of the application can be completed online so that only a few forms need to be printed, completed, and mailed to TMHP.
•Applicants can view both incomplete and complete applications that have been submitted online.
•Some form fields are automatically completed, reducing the amount of information that has to be entered.
•Providers can complete the Provider Information Change (PIC) form online.
•Providers will receive e-mail notifications when messages or deficiency notices about their applications are posted online. Providers may opt out of e-mail communication and receive messages or deficiency letters by mail.
To be eligible for Texas Medicaid reimbursement, a provider of medical services (including an out-of-state provider) must:
•Meet all applicable eligibility criteria.
•Be approved by HHSC for enrollment.
•Obtain an NPI from NPPES.
•File with TMHP the required Texas Medicaid enrollment application ensuring that the application is correct, complete, and includes all required attachments and additional information.
•Meet all applicable criteria for eligibility to enroll (Refer to "Out-of-State Medicaid Providers" for criteria specific to out-of-state providers).
•Provide any additional information requested by TMHP, HHSC, or the HHSC Office of Inspector General in connection with the processing of the application.
•Be approved by HHSC for enrollment and enter into a written provider agreement with HHSC
Enrolling online promotes accurate submissions, decreases processing time, and enables immediate feedback on the status of the application.
As an alternative to applying for enrollment online, a provider may file a paper enrollment application with TMHP. Providers may download the Texas Medicaid Provider Enrollment Application at www.tmhp.com or request a paper application form by contacting TMHP directly at 1-800-925-9126. A paper enrollment application may also be requested from the following address. Completed paper enrollment applications must also be submitted to the following address:
Texas Medicaid & Healthcare Partnership
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
Note: During the Texas Medicaid enrollment process, with HHSC approval, the Claims Administrator may waive the mandatory prerequisite for Medicare enrollment for certain providers whose type of practice will never bill Medicare (e.g., pediatrics, obstetrician/gynecologist [OB/GYN]).
Providers must maintain a valid, current license or certification to be entitled to Texas Medicaid reimbursement. Providers cannot enroll in Texas Medicaid if their license or certification is due to expire within 30 days of application. A current license or certification must be submitted, if applicable.
Refer to: "Copy of License/Temporary License/Certification" .
A provider identifier is issued when a determination has been made that a provider qualifies for participation.
Refer to: "Out-of-State Medicaid Providers" for additional criteria that must be met for out-of-state providers to enroll in Texas Medicaid.
There are four types of enrollment for providers in Texas Medicaid, as follows:
•Individual. This type of enrollment applies to an individual health-care professional who is licensed or certified in Texas, and who is seeking enrollment under the name, and social security or tax identification number of the individual. An individual may also enroll as an employee, using the tax identification number of the employer. Certain provider types must enroll as individuals, including the following; dieticians, licensed vocational nurses, occupational therapists, registered nurses, and speech therapists.
•Group. This type of enrollment applies to health-care items or services provided under the auspices of a legal entity, such as a partnership, corporation, limited liability company, or professional association, and the individuals providing health-care items or services are required to be certified or licensed in Texas. The enrollment is under the name and tax identification number of the legal entity. For any group enrollment application, there must also be at least one enrolling performing provider.
•Performing provider. This type of enrollment applies to an individual health care professional who is licensed or certified in Texas, and who is seeking enrollment under a group. The enrollment is under the tax identification number of the group, and payment is made to the group. If a health-care professional is required to enroll as an individual, as explained above, but the person is an employee and payment is to be made to the employer, the health-care professional does not enroll as a performing provider. Instead, the health-care professional enrolls as an individual provider under the tax identification number of their employer.
•Facility. This type of enrollment applies to situations in which licensure or certification applies to the entity. Although individuals working for or with the entity may be licensed or certified in their individual capacity, the enrollment is based on the licensure or certification of the entity. For this reason, facility enrollment does not require enrollment of performing providers. However, certain provider types must enroll as facilities, including the following:
•Ambulance and air ambulance
•Ambulatory surgical center (ASC) and hospital-based ambulatory surgical center (HASC)
•Birthing center
•Catheterization lab
•Chemical dependency treatment facility (licensed by the Texas Commission on Alcohol and Drug Abuse)
•Consumer Directed Services Agency
•County Indigent Health Care Program
•Community mental health center
•Comprehensive health center
•Comprehensive outpatient rehabilitation facility/outpatient rehabilitation facility
•Department of Assistive and Rehabilitative Services Division for Blind Services
•Durable medical equipment (DME)
•Durable medical equipment home health
•Early Childhood Intervention
•Federally Qualified Health Center (FQHC) (may also enroll as a dental group)
•Freestanding psychiatric facility
•Freestanding rehabilitation facility
•Home Health/Home and community support services agency
•Hospital/critical access hospital/out-of-state hospital
•Military hospital
•Hyperalimentation
•Independent diagnostic testing facility/physiological lab
•Indian Health Services
•Independent laboratory
•Maternity services clinic
•Mental health/mental retardation case management
•Mental health rehabilitation case management
•Mental retardation diagnostic services case management
•Milk bank donor
•Personal care services
•Pharmacy
•Portable X-ray
•Radiation treatment center
•Radiological laboratory
•Renal dialysis facility
•Rural health center (RHC) (may also enroll as a dental group)
•School health and related services (SHARS)/non-school SHARS
•Service responsibility option
•Skilled nursing facility
•Vision medical supplier
•Women, Infant and Children
Providers must submit a separate Texas Medicaid Provider Enrollment Application for each enrollment type requested. For example, a health-care professional who is already enrolled with Texas Medicaid as an individual with his or her own practice, and who wishes to bill for services provided in connection with a group, must submit a separate enrollment application and be approved as a performing provider with the group. Similarly, a health-care professional who is enrolled as a performing provider with one group, but who wishes to bill for services provided in connection with another group, must submit a separate enrollment application and be approved as a performing provider with the other group.
Note: A separate provider identifier is issued for each enrollment type that is approved. The provider is authorized to use the provider identifier only to bill for services provided as indicated in the approved enrollment application. It is a program violation for a provider to use a provider identifier for any purpose other than billing for the types of services, and under the type of enrollment, for which that provider identifier was issued. Improper use of a provider identifier constitutes program abuse and/or fraud. Refer to: "Medicare/Medicaid Waste, Abuse, and Fraud Policy" for additional information.
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