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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 1: Provider Enrollment and Responsibilities

Section 1: Provider Enrollment and Responsibilities
1.1 Provider Enrollment 1-3
1.1.1 National Provider Identifier (NPI) and Taxonomy Codes 1-3
1.1.2 Online Enrollment 1-3
1.1.3 Provider Enrollment Application Determinations 1-7
1.1.3.1 Provider Identifiers Deactivated After 24 Months of No Claim Activity 1-8
1.1.3.2 Excluded Entities and Providers 1-8
1.1.4 Enrollment in Medicaid Managed Care Programs 1-9
1.1.5 Required Enrollment Forms 1-9
1.1.5.1 Texas Medicaid Provider Enrollment Application 1-9
1.1.5.2 HHSC Medicaid Provider Agreement 1-10
1.1.5.3 Provider and Principal Information Forms 1-10
1.1.5.4 Disclosure of Ownership and Control Interest Statement 1-10
1.1.5.5 Internal Revenue Service (IRS) W‑9 Form 1-11
1.1.5.6 Medicaid Audit Information Form 1-11
1.1.5.7 Corporate Board of Directors Resolution 1-11
1.1.5.8 Certificate of Good Standing (Board Corporation Act, Article 2.45) 1-11
1.1.5.9 Certificate of Formation or Certificate of Filing/Certificate of Incorporation 1-11
1.1.5.10 Certificate of Filing 1-11
1.1.5.11 Copy of License/Temporary License/Certification 1-11
1.1.5.12 Licensure Renewal 1-12
1.1.5.13 Medicare Participation 1-12
1.1.5.14 Group Information Changes 1-13
1.2 Payment Information 1-13
1.2.1 Using EFT 1-13
1.2.2 Advantages of EFT 1-13
1.2.3 EFT Enrollment Procedures 1-14
1.2.4 Stale-Dated Checks 1-14
1.3 Provider Reenrollment 1-14
1.3.1 Medicare Number 1-14
1.3.2 Provider Status (Individual, Group, Performing Provider, or Facility) 1-14
1.3.3 Physical Address 1-15
1.3.4 Change in Principal Information 1-15
1.4 Change of Ownership Requirements 1-15
1.5 Provider Responsibilities 1-16
1.5.1 Compliance with Texas Family Code 1-16
1.5.1.1 Child Support 1-16
1.5.1.2 Reporting Child Abuse or Neglect 1-16
1.5.1.3 Procedures for Reporting Abuse or Neglect 1-17
1.5.1.4 Procedures for Reporting Suspected Sexual Abuse 1-17
1.5.1.5 Training 1-18
1.5.2 Maintenance of Provider Information 1-18
1.5.2.1 NPI Verification 1-19
1.5.2.2 Online Provider Lookup (OPL) 1-19
1.5.3 Retention of Records and Access to Records and Premises 1-20
1.5.3.1 Payment Error Rate Measurement (PERM) Process 1-22
1.5.4 Release of Confidential Information 1-22
1.5.5 Compliance with Federal Legislation 1-23
1.5.6 Tamper-Resistant Prescription Pads 1-23
1.5.7 Utilization Control — General Provisions 1-24
1.5.8 Provider Certification/Assignment 1-24
1.5.8.1 Delegation of Signature Authority 1-25
1.5.9 Billing Clients 1-26
1.5.9.1 Client Acknowledgment Statement 1-27
1.5.10 General Medical Record Documentation Requirements 1-28
1.5.11 Informing Pregnant Clients About CHIP Benefits 1-29
1.6 Enrollment Criteria for Out-of-State Providers 1-30
1.7 Medicaid Waste, Abuse, and Fraud Policy 1-31
1.7.1 Reporting Waste, Abuse, and Fraud 1-39
1.7.2 Suspected Cases of Provider Waste, Abuse, and Fraud 1-39
1.7.3 Employee Education on False Claims Recovery 1-40
1.7.4 Managed Care Organization (MCO) Special Investigative Unit (SIU) 1-40
1.7.5 MCO SIU Case Referrals 1-40
1.8 Texas Medicaid Limitations and Exclusions 1-41
1.9 Forms 1-44
1.1 Authorization to Release Confidential Information (2 Pages) 1-45
1.2 Authorization to Release Confidential Information (Spanish) (2 Pages) 1-47
1.3 Child Abuse Reporting Guidelines (2 Pages) 1-49
1.4 Child Abuse Reporting Guidelines, Checklist for HHSC Monitoring 1-51
1.5 Electronic Funds Transfer (EFT) Authorization (2 Pages) 1-52
1.6 Private Pay Agreement 1-54
1.7 Provider Information Change (PIC) Form Instructions 1-55
1.8 Provider Information Change Form 1-56

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.