Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.
The Centers for Medicare & Medicaid Services (CMS) assigns National Provider Identifiers (NPIs) to providers through the National Plan and Provider Enumeration System (NPPES). NPIs are used to track health care providers for billing and quality reporting.
Reminder: Taxonomies must be on file and up to date in NPPES for providers to successfully enroll and revalidate enrollment in the Provider Enrollment and Management system (PEMS). Providers must ensure that their taxonomy codes on the NPPES website remain up to date and accurate for the appropriate programs and service types in PEMS.
Providers cannot perform enrollment functions in PEMS if their enrolling/revalidating taxonomy is not on file with NPPES. Eligible Texas Medicaid taxonomies are displayed in PEMS on the NPI Taxonomy Information page.
- An eligible taxonomy is a taxonomy that is on file with NPPES for a given NPI and is eligible for enrollment in Texas Medicaid.
The Texas Health and Human Services Commission (HHSC) requires all providers with Texas Medicaid enrollment to ensure that all taxonomies used to bill for Medicaid services are enrolled in PEMS. Enrolled taxonomies are identified on the Programs and Services Participation tab of each Practice Location in PEMS.
- 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 that they have enrolled with for billing purposes. If providers do not use an enrolled taxonomy for claims, they will not receive reimbursement.
Note: Users may need to click the Refresh Information button on the NPI Taxonomy Information page to view the information on file with NPPES.
Additional information is available in the web article that was posted to tmhp.com on March 1, 2023.
For information about eligible and enrolled taxonomies and PEMS, providers can access the Taxonomies and Enrollment video available on the PEMS playlist on the Texas Medicaid & Healthcare Partnership (TMHP) YouTube channel.
Note: Providers with an Atypical Provider Identifier (API) should choose a taxonomy, but TMHP will not check the taxonomy with NPPES.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.