This article has been updated. To view the updated information, click here.
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.
Effective December 31, 2022, a separate provider type (PT) will be available for Medicaid enrollment of local health departments (LHDs), including health service regional offices that operate in the capacity of LHDs.
Establishing a separate PT for LHDs will permit these providers to enroll and bill for Medicaid services within their scope of practice.
All current providers enrolled in Medicaid that qualify for LHD services must enroll as an LHD.
The types of services LHD providers will be rendering include immunization services and the screening and treatment for sexually transmitted infections and infectious diseases.
Provider Enrollment Through the Provider Enrollment and Management System (PEMS)
Providers can enroll and select the new PT through PEMS.
The requirements for LHD enrollment are as follows:
- LHDs need to upload their established ordinance letter that indicates that they are a public health department, local public health district, or public health entity.
Note: Providers may not enroll if the letter is due to expire within 30 days.
- All providers that bill laboratory services must have Clinical Laboratory Improvement Amendment (CLIA) certification for the procedure code being billed. If a provider bills for a procedure without appropriate CLIA certification, the Texas Medicaid & Healthcare Partnership (TMHP) will deny reimbursement. Providers must update their CLIA certifications in PEMS under the License/Certification/Accreditation link.
Providers may refer to the CLIA Certification Required for Claims web page for additional information regarding CLIA certification required for claims.
Providers may refer to the TMHP Provider Enrollment and Management System (PEMS) web page for additional information regarding PEMS enrollment.
Attesting NPI Taxonomies
A National Provider Identifier (NPI) can attest to any taxonomy through the National Plan and Enumeration System (NPPES). PEMS will use NPPES to pull information about the NPI, including the list of taxonomies that the provider has attested to.
PEMS will then use the presence of the organization type of the NPI and the specific taxonomy code 261QP0905X to allow the provider to submit an enrollment as an LHD. If the NPI is not for an organization, or it does not attest to this specific taxonomy code, then PEMS will not allow LHD to be selected for enrollment.
Site Visit Requirements
The Texas Health and Human Services Commission (HHSC) is required to screen all new enrollment applications, including applications for a new practice location, change in ownership, reenrollment, and revalidation based on a categorical screen risk level (limited, moderate, or high). HHSC has assigned a risk category of moderate for the LHD provider population, which requires a site visit for initial applications and revalidations.
The preenrollment site visits will be conducted at the locations listed on the enrollment application, including the business office and/or any locations where clients receive LHD services.
A TMHP site visit coordinator will reach out through email or phone to schedule a visit. If the TMHP site visit coordinator is unable to reach a provider, then TMHP will conduct an unannounced site visit.
LHD Procedure Codes
Beginning February 1, 2023, LHD providers will be added as a payable PT for the following procedure codes:
11976 |
11981 |
11982 |
11983 |
58300 |
58301 |
71045 |
71046 |
71047 |
74018 |
80048 |
80051 |
80053 |
80055 |
80061 |
80076 |
80081 |
81000 |
81001 |
81002 |
81003 |
81005 |
81025 |
82040 |
82247 |
82248 |
82465 |
82565 |
82947 |
83036 |
83655 |
83718 |
83721 |
83735 |
84075 |
84443 |
84450 |
84460 |
84478 |
84520 |
85018 |
85025 |
86580 |
86592 |
86689 |
86701 |
86702 |
86703 |
86704 |
86705 |
86706 |
86780 |
86803 |
87015 |
87116 |
87140 |
87164 |
87190 |
87205 |
87207 |
87210 |
87253 |
87270 |
87320 |
87340 |
87341 |
87389 |
87490 |
87491 |
87521 |
87535 |
87556 |
87590 |
87591 |
87661 |
87798 |
87808 |
87810 |
88150 |
88164 |
88175 |
90460 |
90461 |
90471 |
90472 |
90473 |
90474 |
90619 |
90620 |
90621 |
90630 |
90632 |
90633 |
90636 |
90647 |
90648 |
90651 |
90654 |
90655 |
90656 |
90657 |
90658 |
90660 |
90661 |
90662 |
90670 |
90672 |
90673 |
90674 |
90675 |
90680 |
90681 |
90682 |
90685 |
90686 |
90687 |
90688 |
90696 |
90697 |
90698 |
90700 |
90702 |
90707 |
90710 |
90713 |
90714 |
90715 |
90716 |
90723 |
90732 |
90733 |
90734 |
90736 |
90739 |
90740 |
90743 |
90744 |
90746 |
90747 |
90750 |
90756 |
92002 |
92004 |
92014 |
92015 |
96156 |
96158 |
96159 |
96160 |
96161 |
96164 |
96165 |
96167 |
96168 |
96372 |
97802 |
97804 |
98960 |
99000 |
99078 |
99091 |
99202 |
99203 |
99204 |
99205 |
99211 |
99212 |
99213 |
99214 |
99215 |
99381 |
99382 |
99383 |
99384 |
99385 |
99386 |
99387 |
99391 |
99392 |
99393 |
99394 |
99395 |
99402 |
99404 |
99406 |
99407 |
99429 |
99460 |
99461 |
99463 |
99492 |
99493 |
A4267 |
A4268 |
A4269 |
A9150 |
D0120 |
D0140 |
D0145 |
D0150 |
D0160 |
D0170 |
D0180 |
D0210 |
D0220 |
D0230 |
D0240 |
D0270 |
D0272 |
D0274 |
D0330 |
D0340 |
D0350 |
D0367 |
D0460 |
D0470 |
D0601 |
D0602 |
D0603 |
D1110 |
D1120 |
D1206 |
D1208 |
D1310 |
D1330 |
D1351 |
D1352 |
D1510 |
D1516 |
D1517 |
D1520 |
D1526 |
D1527 |
D1551 |
D1552 |
D1553 |
D1556 |
D1558 |
D1575 |
D2140 |
D2150 |
D2160 |
D2161 |
D2330 |
D2331 |
D2332 |
D2335 |
D2390 |
D2391 |
D2392 |
D2393 |
D2394 |
D2740 |
D2750 |
D2751 |
D2752 |
D2791 |
D2792 |
D2920 |
D2930 |
D2931 |
D2932 |
D2933 |
D2934 |
D2940 |
D2950 |
D2954 |
D2971 |
D2999 |
D3110 |
D3120 |
D3220 |
D3221 |
D3230 |
D3310 |
D3320 |
D3330 |
D3346 |
D3347 |
D3348 |
D3351 |
D3352 |
D3353 |
D3999 |
D4211 |
D4277 |
D4278 |
D4283 |
D4285 |
D4341 |
D4342 |
D4355 |
D4910 |
D4999 |
D5110 |
D5120 |
D5211 |
D5212 |
D5213 |
D5214 |
D5410 |
D5411 |
D5421 |
D5422 |
D5520 |
D5612 |
D5630 |
D5640 |
D5650 |
D5660 |
D5670 |
D5671 |
D5720 |
D5721 |
D5730 |
D5731 |
D5740 |
D5741 |
D5750 |
D5760 |
D5761 |
D5820 |
D5821 |
D5899 |
D5992 |
D5993 |
D6240 |
D6549 |
D6750 |
D6930 |
D6999 |
D7111 |
D7140 |
D7210 |
D7220 |
D7230 |
D7250 |
D7270 |
D7286 |
D7510 |
D7550 |
D7910 |
D7961 |
D7962 |
D7970 |
D7971 |
D7997 |
D7999 |
D8080 |
D8210 |
D8220 |
D8660 |
D8670 |
D8680 |
D8690 |
D9110 |
D9210 |
D9211 |
D9212 |
D9215 |
D9223 |
D9230 |
D9243 |
D9248 |
D9310 |
D9430 |
D9630 |
D9910 |
D9930 |
D9944 |
D9951 |
D9974 |
D9999 |
G0433 |
G0439 |
G0475 |
G8431 |
G8510 |
H0033 |
J0561 |
J0696 |
J1050 |
J1580 |
J2001 |
J3490 |
J7297 |
J7298 |
J7300 |
J7301 |
J7307 |
S4993 |
S9441 |
S9445 |
S9470 |
T1002 |
T1003 |
T1007 |
T1015 |
T1017 |
T1019 |
T1023 |
T1027 |
T1029 |
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.