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Coming Soon: PEMS to Be Updated to Allow Provider Credentialing

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Beginning May 30, 2025, the Provider Enrollment and Management System (PEMS) will be enhanced to streamline the process for Texas Medicaid enrollment and managed care organization (MCO) and dental maintenance organization (DMO) credentialing. The new feature will allow a provider to complete and submit their credentialing information as part of the enrollment process, the reenrollment process, or as a maintenance request.

The majority of Medicaid services are delivered through MCOs and DMOs that are licensed by the Texas Department of Insurance (TDI) and contracted by the Texas Health and Human Services Commission (HHSC). Providers that want to provide Texas Medicaid and related services to an MCO or DMO must first enroll with Texas Medicaid before contracting with the MCO or DMO.

PEMS Enhancements

PEMS will feature a new Credentialing Tab for the credentialing application. While the MCO or DMO and the credentials verification organization (CVO) will maintain their credentialing roles, providers will now initiate the credentialing process through PEMS. Although the credentialing application will be accessible in PEMS, it is optional and not required for enrollment, and it does not need to be completed to finalize the Medicaid enrollment application.

Providers must indicate "Yes" or "No" to attest if they wish to credential with an MCO or DMO before submitting their application. If answering "Yes," they must proceed with the credentialing process concurrently with their enrollment application. If they choose to submit the application concurrently, the credentialing application must be completed in its entirety before the Medicaid and credentialing application can be submitted.

Providers that are reenrolling can complete their credentialing during reenrollment.

Note: While PEMS captures the credentialing information, the CVO will verify all information to ensure that it meets credentialing requirements. The CVO is responsible for receiving completed applications, attestations, and primary source verification documents.

Additionally, a new Maintenance - Credentialing Information Request option will be available for enrolled providers seeking to credential with an MCO or DMO.

Credentialing Requirements

The credentialing process involves verifying a health care provider's qualifications, background, and professional standing to ensure that they meet the standards required to deliver care. Providers must submit their application electronically through PEMS, including necessary documents such as proof of education, training, licensure, board certifications, work history, and academic background.

Providers must enroll in PEMS before they can provide Medicaid services. New providers can complete their credentialing during their new enrollment application.

Providers that are actively enrolled in PEMS can use the Maintenance Request to initiate and complete the credentialing process and to submit their credentialing information.

Additional information about credentialing in PEMS will be published in future articles located on tmhp.com.