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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities

Section 1: Provider Enrollment and Responsibilities
Table of Contents
1.1 Provider Enrollment and Reenrollment 5
1.1.1 NPI and Taxonomy Codes 6
1.1.2 Online Enrollment 6
1.1.3 Paper Application Enrollment 7
1.1.4 Provider Enrollment Identification 7
1.1.4.1 Ordering- or Referring-Only Providers 10
1.1.5 Affordable Care Act of 2010 (ACA) Enrollment Requirements 10
1.1.5.1 Provider Screening Requirement 11
1.1.5.2 Provider Re-enrollment 11
1.1.5.3 Application Fee 11
1.1.5.4 Ordering- or Referring-Only Providers Search on the Online Provider Lookup (OPL) 11
1.1.6 Surety Bond Enrollment Requirement 11
1.1.6.1 Ambulance Providers 12
1.1.7 Provider Enrollment Application Determinations 12
1.1.8 Enrollment in Medicaid Managed Care Programs 13
1.1.9 Required Enrollment Forms 14
1.1.9.1 Application Payment Form 14
1.1.9.2 HHSC Medicaid Provider Agreement 14
1.1.9.3 Provider Information Form (PIF-1) 15
1.1.9.4 Principal Information Form (PIF-2) 15
1.1.9.5 Disclosure of Ownership and Control Interest Statement 16
1.1.9.6 Internal Revenue Service (IRS) W‑9 Form 16
1.1.9.7 Medicaid Audit Information Form 16
1.1.9.8 Corporate Board of Directors Resolution 16
1.1.9.9 Franchise Tax Account Status Page 16
1.1.9.10 Certificate of Formation or Certificate of Filing/Articles or Certificate of Incorporation/Certificate of Fact 16
1.1.9.11 Copy of License, Temporary License, or Certification 17
1.1.9.12 Federally Qualified Health Center Affiliation Affidavit 17
1.1.9.13 Physician’s Letter of Agreement 18
1.1.9.14 Licensure Renewal 18
1.1.9.15 Medicare Participation 18
1.1.9.16 Group Information Changes 19
1.2 Payment Information 19
1.2.1 Using EFT 19
1.2.2 Advantages of EFT 19
1.2.3 EFT Enrollment Procedures 20
1.2.4 Receiving Paper Checks 20
1.2.5 Stale-Dated Checks 20
1.3 Provider Deactivation/Disenrollment 20
1.3.1 Excluded Entities and Providers 21
1.4 Provider Reenrollment 21
1.4.1 Medicare Number 22
1.4.2 Provider Status (Individual, Group, Performing Provider, or Facility) 22
1.4.3 Physical Address 22
1.4.4 Change in Principal Information 22
1.5 Change of Ownership Requirements 22
1.6 Provider Responsibilities 23
1.6.1 Compliance with Texas Family Code 23
1.6.1.1 Child Support 23
1.6.1.2 Reporting Child Abuse or Neglect 23
1.6.1.3 Procedures for Reporting Abuse or Neglect 24
1.6.1.4 Procedures for Reporting Suspected Sexual Abuse 25
1.6.1.5 Training 25
1.6.1.6 Reporting Abuse and Neglect of the Elderly or Disabled 25
1.6.1.7 Procedures for Reporting Abuse or Neglect of the Elderly or Disabled 26
1.6.2 Maintenance of Provider Information 26
1.6.2.1 NPI Verification 27
1.6.2.2 Online Provider Lookup (OPL) 27
1.6.2.3 Updating NPI and Taxonomy Codes 29
1.6.2.4 Updating Provider Specialty 29
1.6.3 Retention of Records and Access to Records and Premises 29
1.6.3.1 Payment Error Rate Measurement (PERM) Process 31
1.6.4 Release of Confidential Information 31
1.6.5 Compliance with Federal Legislation 32
1.6.6 Tamper-Resistant Prescription Pads 32
1.6.7 Utilization Control — General Provisions 33
1.6.8 Provider Certification/Assignment 34
1.6.8.1 Delegation of Signature Authority 35
1.6.9 Billing Clients 35
1.6.9.1 Client Acknowledgment Statement 37
1.6.10 General Medical Record Documentation Requirements 38
1.6.11 Informing Pregnant Clients About CHIP Benefits 39
1.6.12 Home Health Providers 40
1.6.12.1 * Home Health Skilled Nursing and Home Health Aide (HHA) Services Provider Responsibilities 40
1.6.13 Private Duty Nursing (PDN) Providers 41
1.6.14 Certified Respiratory Care Practitioner (CRCP) Services 42
1.6.15 Physical, Occupational, and Speech Therapy Providers 42
1.6.15.1 CCP Enrollment for Children’s Services: 20 Years of Age and Younger 42
1.6.16 * Children’s Services Comprehensive Care Program (CCP) 43
1.7 Electronic Health Records (EHR) Incentive Program 43
1.7.1 Attesting to Meaningful Use: Required Documentation for Texas Medicaid EHR Incentive Program 43
1.7.2 How to Return an Electronic Health Records (EHR) Payment 45
1.7.3 EHR Notification and Appeal Process 45
1.8 Computer-Based Training Courses for Providers 45
1.9 Enrollment Criteria for Out-of-State Providers 46
1.10 Medicaid Waste, Abuse, and Fraud Policy 49
1.10.1 Reporting Waste, Abuse, and Fraud 57
1.10.2 Suspected Cases of Provider Waste, Abuse, and Fraud 58
1.10.3 Employee Education on False Claims Recovery 58
1.10.4 Managed Care Organization (MCO) Special Investigative Unit (SIU) 58
1.11 Texas Medicaid Limitations and Exclusions 59
1.12 Forms 62
 

Texas Medicaid & Healthcare Partnership
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