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New Provider Type for Local Health Departments Effective December 31, 2022

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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.