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.
Since the deployment of the Provider Enrollment and Management System (PEMS), the Texas Medicaid & Healthcare Partnership (TMHP) has heard from many providers and used their feedback to enhance the provider user experience.
|Helpful Tips to Avoid Common Enrollment Deficiencies
Disclosing Principals and Managerial Employees
Tip: Providers must disclose all direct and indirect owners and principals in accordance with the Medicare enrollment record, if applicable. Managerial employees or staff who exercise operational control must have a Principal entry in PEMS. The Office of Inspector General (OIG) will compare the applicant’s organizational structure chart and the list of principals in PEMS.
Assumed Name Certificates
Exception: An Assumed Name Certificate is not required if the provider has listed the tax classification as Disregarded Entity.
Tip: Do not include a DBA name on line 2 of the W9 form if it is not a legal DBA that is recognized by the Secretary of State. Each practice location can be given a unique location name that does not have to be recognized as a legal DBA.
Application Fees for Different Programs
Tip: Separate enrollment with the Managed Care Organization (MCO) Long-term Care Services and Support (LTSS) Program is not required if the National Provider Identifier (NPI) and taxonomy combination is already enrolled in PEMS.
|Key Changes That Have Been Implemented
Display Performing Provider Associated to Group
Group practice locations will now display performing providers in the Provider Dashboard in PEMS (when the group is enrolled as both a group and facility).
NPI Verification Against NPPES
Reminder: Providers must have an active National Provider Identifier (NPI) and meet all provider enrollment criteria to remain active in any Texas state health care program. If TMHP determines that a provider NPI is no longer active in the National Plan and Provider Enumeration System (NPPES), the provider will be disenrolled from all Texas state health care programs.
Providers with an inactive NPI accessing PEMS will receive a message that their NPI is inactive.
Providers should contact NPPES at 800-465-3203 to research and resolve any issues with their NPI. TMHP will reverify a provider’s NPI status with NPPES when the next NPPES dissemination file is released.
Providers need to submit revalidation requests prior to the revalidation due date in PEMS. When a draft revalidation request is submitted after the NPI revalidation due date, an error message will display and will prevent submission of the revalidation request. The provider must create and submit a PEMS reenrollment request if the NPI revalidation due date has passed.
Additional information related to revalidation in PEMS is available on the TMHP website:
Duplicate Program Check
When a user adds a program/practice in PEMS and the program/practice matches another program/practice at the same location, the following message will display, “Unable to save a duplicate program record. Please reenroll the Program record with the same Program and Primary Taxonomy or change the Program and Primary Taxonomy to be different than the other duplicate Program record.”
PEMS Enrollment Deficiencies
Providers have a total of 45 business days to complete and resolve all deficiencies when completing their enrollment application. PEMS will display the message, “You must respond to and resolve all deficiencies within 45 business days.”
Kidney Health Care (KHC) Provider Enrollment
KHC requires the user to enter Mailing as Address Type when Social Worker is selected as Contact Type. Users must enter Contact Address as Address Type when Enrollment Contact is selected as Contact Type. This information is required for New Enrollment, Existing Enrollment, Revalidation, Reenrollment, and PEMS Maintenance – Practice Location request types.
Physical Address – Practice Location
PEMS will only allow physical addresses (not P.O. boxes) to be added as a practice location on the Practice Location Information page and on the Ownership/Controlling/Principal Information page in PEMS.
License – Practice Location
On the Program and Services Participation Details page, providers now have the option to remove the Licenses/Certifications/Accreditations that are applied to the program practice record. This will end date the license association to the program practice for licenses that have previously been approved and will display the association’s effective dates for the segments as “Removed.” Licenses that have not been approved and that were added by mistake will not have the termination date added.
Users can add licenses to the program practice record that were previously removed by selecting Reactivate. This will null the earlier termination date.
Physical Therapy/Occupational Therapy Groups
The Medicare Program Specific Questions will now display for Physical/Occupational Therapy groups in PEMS.
Display Practice Location - Physician Letter of Agreement
The performing provider Physician’s Letter of Agreement will display program.
|PEMS Portal Reminder
Updating CLIA Certifications in PEMS
Providers must update their Clinical Laboratory Improvement Amendment (CLIA) certifications in PEMS under the License/Certification/Accreditation link. Providers may find more information about updating CLIA certifications in PEMS on the Licenses/Certifications/Accreditations page on tmhp.com.
Refer to the web article that was posted to tmhp.com on April 7, 2023.
Providers must have access to the internet to access PEMS, and use up-to-date internet browsers for optimum performance of the PEMS portal. TMHP recommends the use of Google Chrome or Microsoft Edge, as legacy Microsoft browsers Internet Explorer and non-Chromium based Edge are no longer compatible with PEMS.
|Claims by First-time Enrolling Providers
|Newly enrolled providers may refer to the current Texas Medicaid Provider Procedures Manual, Section 6, “Claims Filing,” for more information regarding enrollment and claims filing.
|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, visit the Provider Enrollment Help page on tmhp.com.
|PEMS Multi-Factor Authentication for Electronic Funds Transfer (EFT) Updates
Effective June 30, 2023, additional verification is required when EFT (electronic fund transfer) information has been updated on the following PEMS request types: Reenrollment, Revalidation, and Existing Enrollment. A personal identification number (PIN) sent to the email address on file will be needed to make any changes to EFT information.
As a reminder, providers needing to update their email addresses must submit a "Maintenance-Provider Information-Change Email" request to ensure that PEMS has the latest information. Providers may also submit this request if they need to update their email while the request for EFT changes is in flight.
Previous posting from March 21, 2023:
Effective April 15, 2023, additional verification is required for PEMS EFT (electronic fund transfer) changes. A personal identification number (PIN) sent to the email address on file will be needed to make any changes to EFT information. EFT change requests cannot be created within 30 calendar days after approval of a “Maintenance-Provider Information-Change Email” request.
View previous postings below:
- February 28, 2022
- March 11, 2022
- March 29, 2022
- April 11, 2022
- April 25, 2022
- May 9, 2022
- May 23, 2022
- June 2, 2022
- June 20, 2022
- July 1, 2022
- July 18, 2022
- August 1, 2022
- August 15, 2022
- August 29, 2022
- September 12, 2022
- September 26, 2022
- October 10, 2022
- October 24, 2022
- November 9, 2022
- November 21, 2022
- December 5, 2022
- December 19, 2022
- January 17, 2023
- January 30, 2023
- February 13, 2023
- March 21, 2023
- April 18, 2023
- May 16, 2023
- June 30, 2023
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.