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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.1 Provider Enrollment and Reenrollment : 1.1.4 Provider Enrollment Identification

1.1.4
Providers are required to identify the type of entity for which they are requesting enrollment. Providers can choose from one of the following on each application they submit (only one per application is allowed):
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 number 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 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. THSteps providers are only enrolled at the group level.
During the PEP process, the available taxonomy code list is populated with either taxonomy code 193200000X or 193400000X for a clinic/group practice, depending on which specialty is chosen. The taxonomy codes for clinic/group practice 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.
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 or the supervising licensed practitioner who is assuming responsibility for the facility’s operation. 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 that they request unless otherwise approved as a dual enrollment. For example, enrolled hospital providers will be issued a hospital provider identifier that is specific to hospital services and a separate HASC provider identifier that is specific to ambulatory surgical services unless the provider is subject to restricted reimbursement. However, 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.
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:

Texas Medicaid & Healthcare Partnership
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