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Heading: Provider Enrollment
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 Enrolling in the CSHCN Services Program

Chapter 2 of the CSHCN Services Program Provider Manual includes details of the enrollment process.

Providers are encouraged to use Provider Enrollment on the Portal, which completes the enrollment process electronically. Click here for: Online Enrollment

The Paper Enrollment Process

Provider who prefer to submit a paper enrollment application must follow this process. For assistance with the application process, call the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413, Option 2. Retain a copy of the original application for future reference.

After completing the enrollment application providers should send it and the supporting documentation to the following address:

Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795

Applicants 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 and a new enrollment application must be submitted. To prevent unnecessary delays in the enrollment process, applicants should thoroughly review their enrollment application for accuracy and completeness before submitting it to TMHP.

Who must complete a new enrollment form?

Providers wanting to participate in the CSHCN Services Program must complete an enrollment application. Providers of medical services must be actively enrolled as a Texas Medicaid provider as a prerequisite to becoming a CSHCN Services Program provider. This requirement is waived for providers of non-medical program services such as family support providers, funeral homes, meals, lodging, or transportation providers.

A new CSHCN Services Program Provider Enrollment Application must be completed whenever a provider is required to reapply to the Texas Medicaid Program because of a change to the following:

  • Medicare number
  • Ownership
  • Provider status (individual, group, performing provider, or facility)
  • Provider type

Required Paper Enrollment Forms

Providers who are submitting a paper enrollment application to the CSHCN Services Program must complete the following forms:

Children with Special Health Care Needs (CSHCN) Services Program Provider Enrollment Application The application includes:

  • CSHCN Services Program Identification Form
  • Provider Agreement with DSHS for Participation in the CSHCN Services Program
  • Certification Regarding Debarment Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts

All providers

Provider Information Form (PIF-1)

All providers applying for CSHCN Services Program enrollment more than one year from their Texas Medicaid enrollment date.

Principal Information Form (PIF-2)

Each principal of all providers applying for CSHCN Services Program enrollment more than one year from their Texas Medicaid enrollment date.

Disclosure of Ownership Form

All providers applying for CSHCN Services Program enrollment more than one year from their Texas Medicaid enrollment date.

W-9 Request for Taxpayer Identification Number and Certification

All providers

Required Information for Dental/Orthodontia Providers Only

Dental and orthodontic providers

Required Information for Customized Durable Medical Equipment (DME) providers

Providers of customized DME

EFT

Electronics Fund Transfer Agreement

 
   

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