TMPPM 2008 > Texas Medicaid Services > Family Planning Services > Provider Enrollment

20.3 Provider Enrollment

20.3.1 Title XIX Enrollment

Only the following Medicaid provider types may be used to bill family planning services under Title XIX: physician, nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA), certified nurse-midwife (CNM), federally qualified health center (FQHC), or family planning agency. An NP and a CNS must be licensed as a registered nurse (RN) and recognized as an advanced practice nurse (APN) by the Texas Board of Nursing (BON).

Physicians who wish to provide Medicaid obstetric and gynecological (OB-GYN) services are allowed to bypass Medicare enrollment and obtain a Medicaid-only provider identifier for OB-GYN services regardless of provider specialty. Similarly, FQHCs do not need to apply for a separate physician or agency number. Family planning services are payable under the existing FQHC provider identifier using the family planning procedure codes in this section.

Family planning services provided by an RHC will not be paid if billed using the RHC's provider identifier but may be billed using a physician's or NP's provider identifier. An RHC can also apply for enrollment as a family planning agency and bill using the family planning agency's provider identifier. These services provided to an RHC client must be billed using modifiers AJ, AM, SA, or U7. These services must be billed using the appropriate national place of service (72) for an RHC setting.

Family planning agencies must apply for enrollment with TMHP to receive an agency provider identifier. To be enrolled in the Texas Medicaid Program, family planning agencies must meet the following requirements:

•Complete an agency enrollment application.

•Ensure that all services are furnished by, prescribed by, or provided under the direction of a licensed physician in accordance with the Texas Medical Board and/or Texas BON.

•Have a medical director who is a physician currently licensed to practice medicine in Texas, and submit a current copy of the medical director's physician license.

•Have an established record of performance in the provision of both medical and educational/counseling family planning services as verified through client records, established clinic hours, and clinic site locations.

•Provide family planning services in accordance with DSHS standards of client care for family planning agencies.

•Be approved for family planning services by the DSHS Family Planning Program.

The effective date for participation is the date an approved provider agreement with Medicaid is established and the provider is assigned a Medicaid provider identifier.

Providers cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

Important: All providers are required to read and comply with Section 1, Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to the Texas Medicaid Program, it is a violation of Texas Medicaid Program rules when a provider fails to provide health-care services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC §371.1617(a)(6)(A). Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to the Texas Medicaid Program, providers can also be subject to Texas Medicaid Program sanctions for failure, at all times, to deliver health-care items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance.

Refer to: "Provider Enrollment" for more information about enrollment procedures.