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.
Texas Medicaid & Healthcare Partnership’s (TMHP) Provider Enrollment and Management System (PEMS) is coming soon.
Provider enrollment functions will be available through PEMS, and providers must use this new system to enroll in Texas Medicaid.
The new system will be the single tool for provider enrollment, reenrollment, revalidation, change of ownership, and maintenance requests (maintaining and updating provider enrollment record information).
Transition Period Effective December 1, 2021
The last day to submit electronic enrollment applications, fax requests, electronic maintenance requests, or submit these items through Provider Enrollment on the Portal (PEP) or Provider Information Management System (PIMS) is November 30, 2021.
Providers planning to submit paper enrollment applications, fax requests, or maintenance requests should be aware that after November 30, 2021, these will no longer be accepted.
During the transition period of December 1 through December 12, 2021, none of the following items should be submitted, because they will not be accepted:
- Paper or electronic enrollment applications
- Fax requests
- Paper or electronic maintenance requests
- Requests submitted through PEP or PIMS
The last day of the transition period is December 12, 2021.
Due to the upcoming transition to the new PEMS, all applications currently in-flight must be completed by February 15, 2022, with the exception of applications that are under an informal desk review or pending Texas Health and Human Services Commission (HHSC) review. If the application is not completed by this date, the application will be closed, and providers will be required to submit the application through PEMS after February 15, 2022.
PEMS Portal Effective December 13, 2021
Providers should plan for the following changes on December 13, 2021:
- PEMS will replace PEP and PIMS. PEP and PIMS will no longer be available.
- Paper applications for Texas Medicaid provider enrollment will be eliminated.
- Providers must have access to the internet to utilize PEMS, and use up-to-date internet browsers for optimum performance of the PEMS portal. Use Google Chrome or Microsoft Edge to reduce compatibility issues.
- Log on to the TMHP.com Provider Enrollment webpage to begin the online enrollment activities after December 13, 2021.
Texas Medicaid and Other Programs and Services Enrollment Type
- Acute Care Services
- Comprehensive Care Program (CCP)
- Texas Health Steps Dental
- Texas Health Steps Medical
- Healthy Texas Women (HTW)
- Case Management
- HHSC Long Term Care (LTC)
- Managed Care Organizations-Long Term Services and Supports (MCO-LTSS)
- Pharmacy Services
- Medical Transportation Program (MTP)
- Kidney Health Care (KHC)
- Children with Special Health Care Needs (CSHCN) Services Program
- CSHCN Family Support Services (FSS)
- Children’s Health Insurance Program (CHIP)
TMHP User Account
PEMS is accessed through My Account. PEMS access is tied to the National Provider Identifier (NPI) or Atypical Provider Identifier (API) associated with the TMHP User Account. Ensure the NPI has all the current and correct information. After a TMHP User Account is created, follow these best practices for account management:
- Assign at least two administrators.
- Update user permissions as staff changes occur.
- Look for reminders for upcoming enrollment tasks on the Message Dashboard.
Refer to the Portal Security Training Manual, which will be available soon, for help creating a TMHP User Account.
Preparing To Enroll
Before accessing PEMS, providers need to verify they have all of the required information:
- Licenses or certifications, if applicable.
- Identification for the provider and any person who meets the definition of owner, creditor, principal, subcontractor, or managing employee.
- Documentation related to disclosures, if needed.
- Additional required documentation for program participation.
Refer to the checklists on the PEMS Instructional Site for a detailed list of documents and information required to complete applications.
The Centers for Medicare & Medicaid Services (CMS) assigns NPIs to clinicians through the National Plan and Enumeration System (NPPES). NPIs are used to track health care providers for billing and quality reporting.
HHSC asks all providers with Medicaid enrollment to visit NPPES to ensure all taxonomies used to bill for Medicaid services are attested to the providers’ NPI. To attest the NPI:
- Login to the provider account at the NPPES website.
- Review the taxonomies selected (attested) for the NPI.
Next, follow these directions for updating provider taxonomy information in NPPES:
- Sign in using your CMS Identity and Access login credentials.
- Scroll down to “Manage Provider Information.”
- Under the “Action” column, click on the pencil icon to open the provider information editor.
- Make any required changes to the individual categories.
- Enter an Health Information Exchange (HIE) endpoint to allow communication through your HIE with other health care partners. This communication may help improve your HIE measures for the Merit-based Incentive Payment System (MIPS), as well as improve your overall care coordination and referral quality.
- Make sure to click “Error Check” after all changes are made to ensure that the information provided is complete.
- Click “Save and Return to Main Page” in the lower right corner. This will activate a dialogue window.
- Choose “Complete NPI Application” to submit all entered changes to the NPPES.
- Click “Main Page” on the top of the menu bar on the left to return to the NPPES main page. From here, you can make further changes or sign out from the upper right corner.
Reminder: NPPES taxonomies MUST be up-to-date to successfully enroll and revalidate in PEMS. Ensure taxonomy codes on the NPPES website remain up-to-date with the available taxonomy codes used to identify applicable program selections in PEMS. Providers with an API still choose a taxonomy, but it will not be compared with NPPES.
PEMS is an NPI/API-based System
PEMS bases each enrollment request and maintenance tasks on the NPI or API of the provider who is applying or is enrolled rather than on legacy identifiers, such as a Texas Provider Identifier (TPI). PEMS bases each enrollment application on the applying provider’s NPI or API.
Providers who would like to enroll in Texas healthcare programs must do so under one of two categories determined by their NPI information on file with NPPES or API:
An NPI is not required for enrollment for non-healthcare services. However, the provider must attest that they are not a healthcare provider and are unable to obtain an NPI to be assigned an API.
Some examples of providers that may have an API include, but are not limited to:
- Financial Management Services Agencies (FMSAs)
- Community Living Assistance & Support Services (CLASS) – Case Management Agencies
- Transition Assistance Services Agencies
For more information about who may not apply for an NPI, refer to Title 45 Code of Federal Regulations (CFR) §160.103.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.