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WARNING: THIS IS A TEXAS HEALTH AND HUMAN SERVICES INFORMATION RESOURCES SYSTEM THAT CONTAINS STATE AND/OR U.S. GOVERNMENT INFORMATION. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW.
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AMA/ADA End User License Agreement
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT® ")

You, your employees and agents are authorized to use CPT only as contained in materials on the Texas Medicaid & Healthcare Partnership (TMHP) website solely for your own personal use in directly participating in healthcare programs administered by THHS. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, 515 N. State Street, Chicago, Illinois, 60610. Applications are available at the American Medical Association website, www.ama-assn.org/go/cpt.

U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer databases and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer databases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

Disclaimer of Warranties and Liabilities

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the American Medical Association (AMA) is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with THHS, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the for egoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "accept".

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONTINUED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NO AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

1. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights included in the materials.

2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org.

3. U.S. GOVERNMENT RIGHTS. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government Use. This product includes CDT, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago Illinois, 60611. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal Procurements.

4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does no t directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with TMHP or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of the Agreement. The ADA is a third party beneficiary to this Agreement.

5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must exit from this computer screen.

Retroactive Enrollment Periods and Claims Reprocessing

Last updated on 2/13/2025

The Texas Medicaid & Healthcare Partnership (TMHP) and the Texas Health and Human Services Commission (HHSC) have developed a process to modify enrollment period effective dates for providers that meet the following criteria:

Have been disenrolled from Texas Medicaid for failing to revalidate on-time between November 1, 2023, and December 12, 2024.
Successfully reenroll or revalidate in Texas Medicaid by May 31, 2025.

This process will be implemented in two phases.

Phase 1 Overview

Beginning January 17, 2025, for providers that meet both the criteria listed above, Phase 1 will result in their National Provider Identifier (NPI) enrollment period begin date in the Provider Enrollment and Management System (PEMS) to be backdated up to 365 calendar days. This will reduce or eliminate the provider’s enrollment gap impacted by status code 66, “Provider Is Not Enrolled, Failed To Re-Validate.”

Providers will receive an email notification with their new NPI enrollment period begin date. For any providers with draft or in-flight revalidation or reenrollment requests that are approved after January 17, 2025, the following will apply:

Their NPI enrollment period begin date in PEMS will be backdated up to 365 calendar days to reduce or eliminate their enrollment gap.
Status code 66 will be removed up to 365 days after the revalidation or reenrollment is in “closed-enrolled” status.

Phase 2 Overview

Beginning February 22, 2025, Phase 2 will result in shifting the enrollment period end date back the same number of days that the enrollment period begin date was shifted back. The change to the enrollment period end date will also be reflected as a new revalidation due date to align with state and federal revalidation frequency requirements. Providers will receive an email notification with their new NPI enrollment period end date.

Important: Providers should continue to submit all claims during the gap period and during their reenrollment phase. TMHP will be processing claims as normal for services delivered during the gap period.

Retroactive Enrollment Period Examples

To learn more about how these modifications affect enrollment periods, refer to the following examples:

Example 1: Provider’s enrollment period gap exceeds 365 calendar days.
In this scenario, the provider’s enrollment period end date and revalidation due date was November 1, 2023, and the provider was disenrolled for failing to revalidate on-time effective November 2, 2023. The provider successfully reenrolled on November 27, 2024. In Phase 1, the NPI enrollment period begin date in PEMS will be backdated 365 calendar days to November 28, 2023. In Phase 2, the enrollment period end date and revalidation due date will be shifted back to November 27, 2028.
- Current enrollment periods:
  - February 1, 2019 – November 1, 2023
  - November 27, 2024 – November 26, 2029
- Revised enrollment periods after Phase 1 and Phase 2:
  - February 1, 2019 – November 1, 2023
  - November 28, 2023 – November 27, 2028
Example 2: Provider’s enrollment period gap is less than 365 days, and entire gap closure occurs.
In this scenario, the provider’s enrollment period end date and revalidation due date was March 31, 2024, and the provider was disenrolled for failing to revalidate on-time effective April 1, 2024. The provider successfully reenrolled on June 5, 2024. In Phase 1, the NPI enrollment period begin date in PEMS will be backdated to April 1, 2024, because the enrollment gap is less than 365 calendar days. In Phase 2, the enrollment period end date and revalidation due date will be shifted back to March 31, 2029.
- Current enrollment periods:
  - April 1, 2019 – March 31, 2024
  - June 5, 2024 – June 4, 2029
- Revised enrollment periods after Phase 1 and Phase 2:
  - April 1, 2019 – March 31, 2024
  - April 1, 2024 – March 31, 2029

Grace Period to Submit Acute Care FFS Claims Impacted by Enrollment Gap

Starting January 1, 2025, providers will no longer receive claim rejections for “Provider Is Not Enrolled, Failed To Re-Validate” for acute care fee-for-service (FFS) claims submitted to TMHP. TMHP has made an update to allow claims to be submitted and accepted into the claims system while the provider is going through the revalidation or reenrollment process. However, claims submitted before the revalidation or reenrollment request is approved will be denied because the provider was not enrolled or failed to revalidate.

To ensure timely reprocessing, any held claims impacted by the enrollment gap must be submitted to TMHP by February 28, 2025.

Acute Care FFS Claims Reprocessing for Retroactive Enrollment Period Effective Date Updates

Beginning February 2025, TMHP will start reprocessing claims that were denied with explanation of benefits (EOB) 01215, “Provider is not enrolled, failed to re-validate,” or that were denied for lack of timely filing during the provider’s gap. This will occur on a monthly basis.

TMHP will waive the timely filing deadline requirement for claims that fall within the retroactive grace period by extending the 95-day claims and 120-day appeals filing deadlines for submitted claims.

If providers have not revalidated or reenrolled in PEMS, their claims will be denied, and reprocessing of their claims will not occur until the provider’s enrollment status in PEMS reflects “Approved.” When the claims are reprocessed, providers may receive additional payment, which will be reflected on the Remittance and Status (R&S) Report two to three weeks after the start of the claims reprocessing.

For more information regarding the gap closure or acute care FFS claims reprocessing, call the TMHP Contact Center at 800-925-9126.

Managed Care Claims

HHSC has worked with managed care organizations (MCOs), and each MCO will have its own claims reprocessing process. Providers should contact members’ specific MCO for details regarding claims submitted to the MCO.

LTC Claims

Long-term Care (LTC) billing providers must rebill claims that previously rejected due to attending or referring providers not being enrolled. Rebilling should occur after the attending and referring providers have completed revalidation or reenrollment and the necessary updates have been made.

If claims exceed the 365-day timely filing deadline, they will be denied. Providers can call HHSC-LTC Provider Claims Services at 512-438-2200 to request consideration for claims reprocessing, and select the appropriate option:

Option 1 for Nursing Facilities, Hospice, and Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID).
Option 5 for Home and Community-based Services (HCS) and Texas Home Living (TxHmL).

For more information regarding the gap closure, call the TMHP LTC Help Desk at 800-626-4117 (select option 1).