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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 1: Provider Enrollment and Responsibilities : 1.1 Provider Enrollment : 1.1.3 Provider Enrollment Application Determinations

An application for provider enrollment may be approved, approved with conditions, or denied. The provider applicant is issued a notice of the enrollment determination.
When an application for enrollment is approved, with conditions, the applicant has no right of appeal or administrative review of the enrollment determination. The types of conditional enrollment include, among other things:
An application may be approved for time-limited enrollment, meaning the provider is granted a contract to participate in Medicaid for a specific period of time. In this case, the provider is sent a notice that includes the deactivation date of the contract. It is the provider’s responsibility, if the provider chooses to seek continued Medicaid participation, to file a complete and correct reenrollment application before the deactivation date of the provider’s current contract. It is recommended that the provider submit a reenrollment application at least 60 days before the current contract deactivation date, to ensure that the reenrollment application is complete and correct before the deactivation date. This may avoid a lapse between the provider’s current contract and the new contract, if a new contract is granted.
An application may be approved subject to restricted reimbursement, meaning the provider is eligible to have only certain types of claims paid. This includes, among other things, reimbursement of only Medicare crossover claims (i.e., claims with respect to “dual eligible” recipients who are covered by both Medicare and Medicaid).
An application may be denied, in which case a denial notice that explains the basis for denial is sent. The notice also explains the right to make a written request for an administrative review of the denial decision, and the procedures for filing such a request. Any administrative review request must be received within 20 days of the date on the letter and filed in accordance with the instructions provided in the denial notice. HHSC will conduct the administrative review and render a final enrollment determination. The HHSC determination following administrative review is not subject to further appeal or reconsideration.
Claims submitted by newly-enrolled providers must be received within 95 days of the date the new provider identifier is issued, and within 365 days of the date of service. Providers with a pending application should submit any claims that are nearing the 365-day deadline from the date of service. Claims will be rejected by TMHP until a provider identifier is issued. Providers can use the TMHP rejection report as proof of meeting the 365-day deadline and submit an appeal.
Refer to:
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:
TMHP cannot issue a prior authorization before Medicaid enrollment is complete. Upon notice of Medicaid enrollment, by way of issuance of a provider identifier, the provider must contact the appropriate TMHP Authorization Department before providing services that require a prior authorization number to Medicaid clients. 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. For these services, providers have 95 days from the add date of the client’s retroactive eligibility in TMHP’s system to obtain authorization for services that have already been performed. Providers should refer to the specific manual section for details on authorization requirements, claims filing, 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 6: Claims Filing for assistance with claim submission. If additional general information is needed, providers may call the TMHP Contact Center at 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 Contact Center representative.

Texas Medicaid & Healthcare Partnership
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