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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 1: Provider Enrollment and Responsibilities : 1.1 Provider Enrollment : 1.1.2 Online Enrollment

1.1.2
Online enrollment has the following advantages:
Providers will receive e-mail notifications when messages or deficiency notices about their applications are posted online. The messages can be viewed on the secured access portion of the website. Providers may opt out of e-mail communication and receive messages or deficiency letters by mail.
Providers who enroll as a group can assign portions of the application to performing providers to complete. Performing providers can complete their portion of a group application by logging into Provider Enrollment on the Portal (PEP) with their unique user name and password.
Before submitting an application to TMHP for processing, providers are required to review a portable document format (PDF) copy of the application and verify it is complete. Providers are able to edit submitted applications to correct identified deficiencies.
To be eligible for Texas Medicaid reimbursement, a provider of medical services (including an out-of-state provider) must:
File with TMHP the required Texas Medicaid enrollment application ensuring that the application is correct, complete, and includes all required attachments and additional information.
Refer to:
Subsection 2.5, “Out-of-State Medicaid Providers” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for criteria specific to out-of-state providers.
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 and must 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 serve Medicare-eligible individuals (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:
A provider identifier is issued when a determination has been made that a provider qualifies for participation.
Refer to:
Subsection 2.5, “Out-of-State Medicaid Providers” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) 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 federal tax identification number of the individual. An individual may also enroll as an employee, using the federal 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 federal tax identification number of the legal entity. For any group enrollment application other than as a THSteps medical checkup provider group, 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 federal 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 federal 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:
Independent diagnostic testing facility/physiological lab
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.
During the PEP process, the taxonomy code for group providers is populated with either the multi-specialty (193200000X) or single-specialty (193400000X) group taxonomy code dependent on which specialty was chosen.
The multi- or single-specialty taxonomy codes for group providers are accurate and have been approved by HHSC. The most appropriate taxonomy codes should be selected for any performing providers that will be enrolled according to their specific performing provider type and specialty.
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:
Subsection 1.7, “Medicaid Waste, Abuse, and Fraud Policy” in this section for additional information.

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