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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.1 Provider Enrollment and Reenrollment : 1.1.9 Required Enrollment Forms

To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas Medicaid enrollment application, including all required forms as indicated in the application.
All paper documents 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.
Whether they are completing the online application or a paper application, providers can refer to the checklist in the paper Texas Medicaid Provider Enrollment Application for information about required forms and other documentation. 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.
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 entity’s nine-digit federal tax identification number.
Providers can call the TMHP Contact Center at 1‑800‑925‑9126 for help with completing the application. Providers should retain a copy of the original application for future reference.
All pages of the application (excluding instructions) 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, 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 HHSC Medicaid Provider 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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