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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 1: Provider Enrollment and Responsibilities : 1.1 Provider Enrollment : 1.1.5 Required Enrollment Forms : 1.1.5.1 Texas Medicaid Provider Enrollment Application

1.1.5.1
Texas Medicaid Provider Enrollment Application
The Texas Medicaid Provider Enrollment Application must be submitted by all providers who want to enroll in Texas Medicaid, and it must be signed by the person who is applying for enrollment. If the applicant is an entity, a principal of the entity must sign the application.
Refer to the checklist in the Texas Medicaid Provider Enrollment Application. This checklist explains, by provider type, the documents and information that must be provided with the application. Applications must be complete in order to process and issue a provider identifier. Each application/applicant is considered separate and should not be combined.
Note:
If enrolled in Medicare, the provider must submit a copy of the Medicare enrollment letter to enroll in Texas Medicaid. Otherwise the enrollment application will be considered incomplete.
When prompted to enter a tax identification number (tax ID) on either a paper or electronic copy of an enrollment application, the applicant should list the provider or entity’s nine digit federal tax identification number.
Providers can call the TMHP Contact Center at 1‑800‑925‑9126, Option 2, for help with completing the application. Providers should retain a copy of the original application for future reference.
All pages of the application must be present even if the forms are left blank because they are not pertinent to the provider’s situation. Providers will be notified of incomplete applications and will have 30 business days to provide the requested missing information. If the information is not provided within 30 business days, TMHP will terminate the enrollment process. If the provider wants to enroll at a later date, the provider should contact TMHP to determine if a new enrollment application must be submitted. Providers are required to review their enrollment application for correctness and completeness before submitting it to TMHP.
By signing the Medicaid enrollment agreement, a provider is certifying that all information submitted in connection with the application for enrollment is complete and correct. Any false, misleading, or incomplete information submitted in connection with an enrollment application constitutes a Medicaid program violation, and may result in administrative, civil, or criminal liability.
Refer to:

Texas Medicaid & Healthcare Partnership
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