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.
Requirements for a Change of Ownership
On November 18, 2022, per the Centers for Medicare & Medicaid Services (CMS) clarification of rules governing ownership updates, high screen risk category providers are subject to the same screening requirements as a newly enrolling high screen risk category provider when an application is submitted due to a change of ownership (CHOW).
The screening requirements for newly enrolling high screen risk category providers include the following:
- Providers must undergo a preenrollment site visit. The purpose of the site visit will be to verify that the information submitted in the enrollment application is accurate and to determine compliance with federal and state requirements.
- Any owners that have a 5% or greater direct or indirect ownership interest must submit proof of a fingerprint-based criminal background check (FCBC). The provider will be sent a deficiency letter with specific directions and information required to schedule a fingerprinting appointment.
High Risk Providers Adding New Owners or Partners of a Practice in PEMS
In PEMS, adding new direct or indirect owners that have a 5% or more ownership interest or new partners that have any direct or indirect ownership requires new screening at the enrollment level. The screening includes:
- A site visit to verify that the information submitted in the enrollment application is accurate and to determine compliance with federal and state enrollment requirements.
- FCBCs for any owners that have a 5% or greater direct or indirect ownership interest. The provider will be sent a deficiency letter with specific directions and information required to schedule a fingerprinting appointment.
Providers may refer to the ACA Screening Requirements document and the Fingerprinting Requirement Frequently Asked Questions (FAQ) for additional information.
Preenrollment site visits will take place at the locations listed on the enrollment application, including business offices and any locations where clients receive services.
A Texas Medicaid & Healthcare Partnership (TMHP) site visit coordinator will email or call providers to schedule a visit. If the TMHP site visit coordinator is unable to reach a provider, TMHP will conduct an unannounced site visit.
Reminder: The Texas Health and Human Services Commission (HHSC) encourages providers to confirm that their enrollment record with Medicare is up to date.
When a provider’s Medicare enrollment record is up to date and the Medicare enrollment information matches the information in the Medicaid enrollment application, then HHSC may rely on the site visit that Medicare conducted.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.