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Provider Enrollment and Management System (PEMS) Post-Deployment Update

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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.

In the nearly 80 days since the December 13, 2021, deployment of the Provider Enrollment and Management System (PEMS) system, Texas Medicaid & Healthcare Partnership (TMHP) has heard from many providers and used their feedback to enhance the provider user experience. This update highlights the most frequent topics about which providers have communicated a need for additional support or functionality, and is the first of a number of updates which will be issued over the next few weeks. TMHP will be increasing the frequency of updates such as this one in order to share added training modalities, system enhancements, and system changes, all designed to improve functionality based on provider feedback and post-deployment observations.

Performing Provider Enrollment

Enhancement Estimated March, 2022

Currently, multiple enrollments for performing providers or multiple locations under one National Provider Identifier (NPI) cannot be initiated concurrently. The limitation was created to prevent multiple requests from updating the same information and causing conflicts.

System enhancements which will allow concurrent enrollment for performing providers are currently in process. Please note that a new provider must be enrolled completely before they can be associated with multiple locations or groups with concurrent applications.

Enrollment effective date

Enhancement Estimated April, 2022

The Texas Health and Human Services Commission (HHSC) is revising the policy for Medicaid enrollment effective dates to again allow retroactive enrollment to the Medicare certification date for providers with the same Medicare and Medicaid risk category. This will require systems changes to implement and will be applied retroactively to providers that meet risk category criteria and submitted a Medicaid enrollment application on or after December 13, 2021.

System enhancements which allow providers that meet risk category criteria, and submitted a Medicaid enrollment application on or after December 13, 2021, to systematically reprocess any claims that were denied, will move forward and the reprocessing of claims will occur after the system modification.

Enrolling Performing Providers in PEMS

Clarification and Guidance

Frequently Asked Question: How to add a performing provider to a group?

No system change is required. For additional guidance, refer to this article on tmhp.com: https://www.tmhp.com/news/2022-01-11-enrolling-performing-providers-pems

Dashboard View NPI level

Clarification and Guidance

Clarification for users with dashboard rights: Users have described seeing messages that are not related to their location.

Dashboards now include all locations under an NPI. This additional content is a change from the previous system, and is due to a change from Texas Provider Identifier (TPI) to NPI hierarchy. For additional guidance, refer to this article on tmhp.com: https://www.tmhp.com/news/2022-01-11-enrolling-performing-providers-pems

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