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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.

Since the deployment of the Provider Enrollment and Management System (PEMS), Texas Medicaid & Healthcare Partnership (TMHP) has heard from many providers and used their feedback to enhance the provider user experience.

The topics listed in this notification highlight the most frequent issues about which providers have indicated they need additional support. This is the sixth edition of this list, following the first edition that was posted on February 28, 2022.

Topic

Current Status

Enrollment Effective Date

The policy for Medicaid enrollment effective dates will be revised to again allow retroactive enrollment to the Medicare certification date for providers with the same Medicare and Medicaid risk category.

System modifications are tentatively expected to implement on May 6, 2022.

Enhancements will be applied retroactively to providers that meet risk category criteria and have submitted a Medicaid enrollment application on or after December 13, 2021.

TMHP will also systematically reprocess any claims that were denied because of this issue. Reprocessing will occur by the end of May 2022.

Topic

Current Status

Eligible and Enrolled Taxonomies

TMHP is providing the following information to clarify the difference between eligible and enrolled taxonomies for Texas Medicaid. There is a small but important difference between eligible and enrolled taxonomies:

  • An eligible taxonomy is a taxonomy that is on file with the National Plan and Provider Enumeration System (NPPES) for a given National Provider Identifier (NPI) and is eligible for enrollment in Texas Medicaid.
  • An enrolled taxonomy is a taxonomy that is currently enrolled in Texas Medicaid and may be used to submit claims. Providers must use the taxonomy with which they have enrolled for billing purposes. If providers do not use an enrolled taxonomy for claims, they will not receive reimbursement.

The YouTube video “Taxonomies and Enrollment” provides step-by-step instructions as to where providers can find these different types of taxonomies.

To view the completed series of PEMS instructional how-to videos on the TMHP YouTube channel, click here.

Topic

Current Status

Helpful Tips to Reduce Enrollment Application Deficiencies

Check Your Information:

The name on your professional license, your practice location, your National Provider Identifier (NPI), and your Social Security number must match both what is on file with Medicare and what is listed in the Texas Medicaid enrollment application.

Attaching Documents:

  • If you participate in the Electronic Funds Transfer (EFT) Program, don’t forget to attach either a voided check or bank letter.
  • If your organization is a corporation, limited liability company (LLC), or partnership, be sure to attach the required organizational chart.

If you’re not sure how to attach the required additional documentation, visit TMHP’s YouTube channel and watch this recently added how-to video:

Adding Attachments - YouTube

Topic

Current Status

Revalidation

Providers must complete their revalidation before the end of their enrollment period. Providers can complete their revalidation in PEMS up to 120 calendar days before their current due date.

Providers may find more information on the Provider Enrollment web page under “Determine Your Application Type” and can use this information to start their revalidation in PEMS.

Topic

Current Status

PEMS Instructional YouTube Videos

TMHP has developed a series of instructional how-to videos that detail the steps required to update provider enrollment records.

To view the completed series of instructional how-to videos, click here.

View previous postings below:

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