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Provider Practice Location Requirements for Moderate and High Risk Providers; PEP Enhancement for Facilities that Require Licensure, Effective August 24, 2018

Last updated on 7/6/2018

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Updates to practice location requirements for moderate and high risk providers requiring site visits and Provider Enrollment on the Portal will require Department of State Health Services and Health and Human Services Commission-Long Term Care (formerly Department of Aging and Disability Services) license information associated to the enrolling facility, effective August 24, 2018.

Details are available on the TMHP website at www.tmhp.com.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.

Provider Practice Location Requirements for Moderate and High Risk Providers

To be compliant with Title 42 Code of Federal Regulations (CFR) §455.432, all providers that have a moderate or high screen risk category and submit a maintenance request via the Provider Information Change (PIC) form, or online via Provider Information Management System (PIMS), to add a new practice location or change the address of an existing practice location, will require an on-site visit. Providers can only submit one practice location address request and one Texas Provider Identifier (TPI) per PIC form. Providers may not render or submit claims for services until the practice location has passed the site visit and has been added to the enrollment record.

Enhancements to PIMS

PIMS will no longer allow providers who have a moderate or high screen risk to fully complete an address update to add a new practice location or changing the address of an existing practice location. Once the practice location update is initiated, the change request will require TMHP review for site visit purposes.

Providers cannot render or submit claims for services at a new practice location until it has been approved and added to the enrollment record. Providers are encouraged to check PIMS for verification that the practice location has been approved prior to rendering or submitting claims for services.

Enhancements to Provider Enrollment on the Portal (PEP)

PEP will be enhanced to make the License, Accreditation, and Certification section of the Provider Information Form (PIF-1) a required field for the following providers licensed by DSHS and HHSC-LTC (formerly DADS):

  • Ambulance/Air Ambulance
  • Ambulatory Surgical Center (ASC)
  • Birthing Center
  • Home and Community Support Services Agency (HCSSA)
  • Hospital
  • Skilled Nursing Facility
  • Chemical Dependency Treatment Facility
  • Home Health
  • Prescribed Pediatric Extended Care Center
  • Personal Assistant Services

Note: Previously saved templates in PEP will not be available after this enhancement takes place.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.