TMPPM 2007 >1.1 Provider Enrollment

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).

A provider of medical services (including an out-of-state provider) who wants to be eligible for Texas Medicaid reimbursement must obtain an NPI from NPPES, complete the required Texas Medicaid provider enrollment application forms, and enter into a written provider agreement with HHSC. TMHP Provider Enrollment supplies these forms. Request forms from and submit completed forms to the following address:

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

Providers may download the Texas Medicaid Provider Enrollment Application at www.tmhp.com.

Note: During the Texas Medicaid Program enrollment process, the Claims Administrator may waive the mandatory prerequisite for Medicare enrollment for certain providers whose type of practice is pediatric-based and who will never bill Medicare.

A provider identifier is issued when TMHP determines that a provider qualifies for participation.

Refer to: "Medicaid Service Provided Outside Texas" for additional criteria that must be met for out-of-state providers to enroll in the Texas Medicaid Program.

A new enrollment application must be completed and a new provider identifier must be issued when one of the following changes:

•Medicare Number-If Medicare has issued a new Medicare number, the provider must complete and submit a Texas Medicaid Provider Enrollment Application in order to enroll the new location or with a new group.

•Change of Ownership-The new owner must do the following:

•Obtain recertification as a Title XVIII (Medicare) facility under the new ownership.

•Complete the Texas Medicaid Provider Enrollment Application.

•Provide TMHP with a copy of the Contract of Sale (specifically, a signed agreement that includes the identification of previous and current owners in language that specifies who is liable for overpayments that were identified subsequent to the change of ownership, that includes dates of service before the change of ownership).

•Provide a listing of all of the provider identifiers affected by the change of ownership.

•Submit any change in ownership, corporate officers, or directors to TMHP Provider Enrollment within 10 calendar days of the change.

•Provider Status (individual, group, performing provider, or facility)-Providers leaving group practices must send a signed letter on company letterhead to TMHP that states the date of termination. The letter should include the provider identifier, effective date of termination, and the group's provider identifier. The letter should be signed by an authorized representative of the group or the individual provider leaving the group. If the provider is joining a new group practice or enrolling as an individual, the provider must complete and submit a Texas Medicaid Provider Enrollment Application to request enrollment in the new group or as an individual provider.

•Physical Address-If a provider is changing an address, and the address is within the Medicare locality, the provider must complete and submit a Provider Information Change (PIC) Form. A W9 is required if the provider is changing the mailing address. If the address is not within the Medicare locality and Medicare has issued a new Medicare number, the provider must complete and submit a Texas Medicaid Provider Enrollment Application in order to enroll the new location. Dental providers must complete a TMHP Dental Provider Enrollment Application for each practice location.

•Provider Type-Providers must submit a separate Texas Medicaid Provider Enrollment Application for each provider type enrollment requested.

TMHP must receive all claims for Texas Medicaid Program services within 95 days of each date of service or within 95 days of the date the provider identifier is issued, whichever occurs later. Claims will be rejected until TMHP has issued an actual provider identifier.

Note that all claims for services rendered to Texas Medicaid clients who do not have Medicare benefits are subject to a filing deadline from the date of service of:

•95 days for in-state providers.

•365 days for out-of-state providers.

TMHP cannot issue a prior authorization before Medicaid enrollment is complete. Upon receipt of notice of Medicaid enrollment, the provider must contact the appropriate TMHP Authorization Department before providing services to a Medicaid client that require a prior authorization number. Regular prior authorization procedures are followed after the TMHP Prior Authorization Department has been contacted. Retroactive authorizations will not be issued unless the regular authorization procedures for the requested services allow for authorizations to be obtained after services are provided. Providers should refer to the specific manual section for details on authorization requirements and any timeframe guidelines for authorization request submissions.

Providers who have not been assigned a provider identifier and have general claim submission questions may refer to Section 5, "Claims Filing" for assistance with claim submission. If additional general information is needed, providers may call 1-800-925-9126 to obtain information. Due to HIPAA privacy guidelines, specific client and claim information cannot be provided. Providers who have already been assigned a provider identifier and have questions about submitting claims, may call the same number and select the option to speak with a TMHP call center representative.

Providers must maintain a valid, current license or certification to be entitled to Texas Medicaid Program reimbursement. Providers cannot enroll in the Texas Medicaid Program 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" .