Instructions for Completing the Provider Type Identification Form

• Select your Applicant Type under “Applicant is enrolling as.”
  Important: The entity type that you select must match the entity type that is on file with the National Plan Provider Enumeration System (NPPES) for your NPI.
• Ordering/Referring—PEP will automatically populate this section for Ordering/Referring providers.
• The "Individual" applicant type is for individual health-care providers that are licensed or certified in the state where they provide services.
• The "Performing Provider" applicant type is for individual health-care providers that are licensed or certified in the state where they provide services.
• The "Group" applicant type is for an entity that is made up of one or more individual health-care providers: the entity and individuals are licensed or certified in the state where services are provided.
• Note: You must enroll as a facility for your Texas Health Steps Medical enrollment if you are a Clinic/Group Practice provider.
• The "Facility" applicant type is for entities that are licensed or certified in the state where they provide services.
• Note: Your "Enrolling As" selection must match the selection you made for your Traditional Medicaid enrollment.
• Check the box that states, “I understand that in the future if I wish to seek reimbursements for services performed to Medicaid recipients I must submit a new enrollment application to be eligible for Medicaid billing.”
• Select “Yes” or “No” to the “Are you using a Medicare certification number for this enrollment?”
  • Note: You must be enrolled in Medicare if you render services to Medicaid clients who are also Medicare clients. If you are eligible, you can make a Medicare Waiver Request.
  • STOP: If your Medicare Certification Number is pending, do not complete the rest of this application. You can complete the application after you receive your Medicare Certification Number. The effective date of your enrollment may be retroactive to your Medicare certification date. Once an enrollment determination has been made, you will receive a notification letter that contains the effective beginning and end dates of your enrollment period. The notification letter will be sent to the physical address that is listed on your application.
  • If you selected “No,” read the Medicare Acknowledgement Statement and check the box for acknowledgment.
  • If it is required, select the appropriate option that matches your Medicare Wavier Request.
  • If it is required, provide a detailed explanation of your situation for your Medicare Waiver Request.
• Enter your National Provider Identifier in the field for “National Provider Identifier (NPI)."
• Verify that the NPI in the “National Provider Identifier (NPI)" field is correct.
• Click Verify NPI.
  WARNING: The entity type that you selected in the “Applicant Is Enrolling As” must match the information that is on file with the National Plan Provider Enumeration System (NPPES) for your NPI. If it doesn’t match, you must go back to the “Applicant Enrolling As” field and change your entity type.
• Choose a provider type from the Traditional Services, Case Management Services, or Comprehensive Care Program (CCP) Services section.
• You can only select one provider type.
• PEP will only allow you to select eligible provider types.
• Hospitals will have both "Hospital (In-State and Out-of-State)" and "HASC" preselected.
• The provider type that you select must match the provider type that is currently on file for your TPI.
• Select a service (Dentist, Oral, and Maxillofacial Surgery, and Orthodontia).
• You can only select one service.
• Select “Yes” or “No” for “Would you like to submit claims electronically?”
• If applicable, select “Yes” or “No” for “Do you currently receive free vaccines from the State of Texas?”
  • Select “Yes” or “No” for “Does your clinic/practice provide routine recommended vaccines to children ages 0 to 18 years?”
    • If you do not participate in the Texas Vaccines for Children Program (TVCP), select No, and answer the next question.
    • If Yes, click on the link to the TVFC form on the DSHS website.
• Click Continue and Save.