The Texas Medicaid & Healthcare Partnership (TMHP) and the Texas Health and Human Services Commission (HHSC) have extended the revalidation due dates and enrollment period gap closure flexibilities to November 30, 2025.
Providers that have started the revalidation or reenrollment process should complete applications and address any outstanding deficiencies as soon as possible to minimize any delays or challenges.
Providers that have not yet begun the revalidation process should start as soon as possible. Providers can start the revalidation process 180 calendar days prior to their revalidation due date. They can verify their revalidation due date on the Provider Information page in the Provider Enrollment and Management System (PEMS).
Revalidation Due Date Extensions
Providers that are due for revalidation between December 13, 2024, and November 30, 2025, will receive an additional 180 calendar days to complete revalidation in PEMS. PEMS will check daily for all providers that are due for revalidation the following calendar day, and if the provider has not completed revalidation, PEMS will automatically add a one-time extension of 180 calendar days to the current revalidation due date.
The extension will be reflected in the Revalidation Due Dates column found on the Provider Information page in PEMS. Providers will also receive an email notification confirming their new revalidation due date. This extension will allow providers additional time to submit and complete PEMS revalidation requests and prevent disenrollment.
Important: A provider’s revalidation is not complete until their revalidation request is in “closed-enrolled” status. Submitting the revalidation request is the first step of the process. The revalidation request must then go through the review process and be approved by TMHP.
Retroactive Enrollment Period Effective Dates
TMHP and HHSC have developed a process to modify enrollment period effective dates for providers that meet the following criteria:
- Have been disenrolled from Texas Medicaid for failing to revalidate on-time between November 1, 2023, and December 12, 2024.
- Successfully reenroll or revalidate in Texas Medicaid by November 30, 2025.
For providers that meet both these criteria, the provider’s National Provider Identifier (NPI) enrollment period begin date in PEMS will be backdated up to 365 calendar days to reduce or eliminate the enrollment gap.
Providers will receive an email notification with their new NPI enrollment period begin date.
Retroactive Enrollment Period Examples
To learn more about how these modifications affect enrollment periods, refer to the following examples:
Example 1: Provider’s enrollment period gap exceeds 365 calendar days.
In this scenario, the provider’s enrollment period end date and revalidation due date was November 1, 2023, and the provider was disenrolled for failing to revalidate on time effective November 2, 2023. The provider successfully reenrolled on November 27, 2024.
- Current enrollment periods:
- February 1, 2019–November 1, 2023
- November 27, 2024–November 26, 2029
- Revised enrollment periods:
- February 1, 2019–November 1, 2023
- November 28, 2023–November 27, 2028
Example 2: Provider’s enrollment period gap is less than 365 days, and entire gap closure occurs.
In this scenario, the provider’s enrollment period end date and revalidation due date was March 31, 2024, and the provider was disenrolled for failing to revalidate on time effective April 1, 2024. The provider successfully reenrolled on June 5, 2024.
- Current enrollment periods:
- April 1, 2019–March 31, 2024
- June 5, 2024–June 4, 2029
- Revised enrollment periods:
- April 1, 2019–March 31, 2024
- April 1, 2024–March 31, 2029
Grace Period to Submit Acute Care FFS Claims Impacted by Enrollment Gap
Starting January 1, 2025, providers will no longer receive claim rejections for “Provider Is Not Enrolled, Failed To Re-Validate” for acute care fee-for-service (FFS) claims submitted to TMHP. TMHP has made an update to allow claims to be submitted and accepted into the claims system while the provider is going through the revalidation or reenrollment process. However, claims submitted before the revalidation or reenrollment request is approved will be denied because the provider was not enrolled or failed to revalidate.
Acute Care FFS Claims Reprocessing for Retroactive Enrollment Period Effective Date Updates
Beginning February 2025, TMHP will start reprocessing claims that were denied with explanation of benefits (EOB) 01215, “Provider is not enrolled, failed to re-validate,” or that were denied for lack of timely filing during the provider’s gap. This will occur on a monthly basis.
TMHP will waive the timely filing deadline requirement for claims that fall within the retroactive grace period by extending the 95-day claims and 120-day appeals filing deadlines for submitted claims.
If providers have not revalidated or reenrolled in PEMS, their claims will be denied, and reprocessing of their claims will not occur until the provider’s enrollment status in PEMS reflects “Approved.” When the claims are reprocessed, providers may receive additional payment, which will be reflected on the Remittance and Status (R&S) Report two to three weeks after the start of the claims reprocessing.
For more information regarding the gap closure or acute care FFS claims reprocessing, call the TMHP Contact Center at 800-925-9126.
Managed Care Claims
HHSC has worked with managed care organizations (MCOs), and each MCO will have its own claims reprocessing process. Providers should contact members’ specific MCO for details regarding claims submitted to the MCO.
LTC Claims
Long-term care (LTC) billing providers must rebill claims that previously rejected due to attending or referring providers not being enrolled. Rebilling should occur after the attending and referring providers have completed revalidation or reenrollment and the necessary updates have been made.
If claims exceed the 365-day timely filing deadline, they will be denied. Providers can call HHSC-LTC Provider Claims Services at 512-438-2200 to request consideration for claims reprocessing, and select the appropriate option:
- Option 1 for Nursing Facilities, Hospice, and Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID)
- Option 5 for Home and Community-based Services (HCS) and Texas Home Living (TxHmL)
For more information regarding the gap closure, call the TMHP LTC Help Desk at 800-626-4117 (select option 1).
PEMS Revalidating and Reenrollment References
Providers may refer to the PEMS educational videos on TMHP’s Provider Enrollment & Management System Playlist on YouTube, which includes the following:
- Revalidating an Individual
- Revalidating a Performing Provider
- Revalidating a Clinic/Group Practice or Facility
The following resources provide more information about Medicaid provider revalidation requirements and common deficiencies to avoid:
- Common Deficiencies Identified by OIG
- Provider Enrollment Revalidation in PEMS
- ACA Screening Requirements
Providers may refer to the Provider Enrollment Help page or the PEMS Instructional Site on tmhp.com for additional revalidation or reenrollment support.