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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.1 Provider Enrollment and Reenrollment : 1.1.7 Provider Enrollment Application Determinations

An application for provider enrollment may be approved for a 3- to 5-year enrollment depending on provider type, approved with conditions, or denied. The provider applicant is issued a notice of the enrollment determination.
Refer to:
Subsection 1.1.5, “Affordable Care Act of 2010 (ACA) Enrollment Requirements” in this section for additional information about the ACA 3- to 5-year re-enrollment requirement.
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.
The enrollment date is the day on which a new TPI was issued. This date impacts claims filing deadlines.
Refer to:
HHSC determines effective dates as follows:
For providers who are required to enroll in Medicare, the Medicaid effective date will be the Medicare effective date or the license, certification, contract, or program implementation effective date, whichever is most current.
For providers who are not required to enroll in Medicare, the Medicaid effective date will be one year prior to the receipt of the complete application or the license, certification, contract, or program implementation effective date, whichever is most current.
Notification letters that contain the new enrollment information are printed the following business day and mailed to the physical address listed on the application. The enrollment date and effective dates do not change when revalidating or reactivating an existing TPI, so new enrollment notification letters are not generated.

Texas Medicaid & Healthcare Partnership
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