Requirements

Required Licenses and Certifications

Patient Protection and Affordable Care Act Information

Additional Program Enrollment

Identification

• providers must submit the following:
• National Provider Identifier (NPI)
• Primary Taxonomy Code
• Federal Employer Identification Number (EIN)
• Existing Texas Provider Identifier (TPI)
• Tax Classification
• Medicare enrollment information
• A provider and any individual who meets the definition of a principal, medical director, creditor, or subcontractor of the provider must submit the following:
• Social Security Number
• Date of birth
• Driver’s license information
• Professional license information (if applicable)
• Copy of documentation that demonstrates current compliance with court-ordered child support or a court-approved compliance agreement (if applicable)
• Copy of Green Card, Visa, or other documentation that demonstrates the right to reside and work for each individual who is not a U.S. citizen

Required Documentation

• providers must submit the following application forms:
• Provider Enrollment Application:
• Texas Medicaid Provider Type Identification Form (One form must be submitted for each facility, group, performing provider, and individual that is enrolling.)
• Provider Information Form (PIF-1)
• Copy of the facility license
• HHSC Medicaid Provider Agreement (One agreement must be submitted for each group, performing provider within the group, individual, and facility that is enrolling.)
• HHSC Medicaid Ordering or Referring Provider Agreement (Ordering or Referring-Only Providers)
• Form W-9
• Principal Information Form (PIF-2) (Each principal, medical director, subcontractor, and creditor of the provider must submit an individual form.)
• CSHCN Services Program Identification Form
• Provider Agreement with the Texas Health and Human Services Commission (HHSC) for Participation in the Children with Special Health Care Needs (CSHCN) Services Program
• Electronic Funds Transfer (EFT) Notification and a copy of a voided check or a signed letter from the bank, if enrolling in EFT
• A link will be provided after you submit your application if fingerprinting is required.
• Application fee or proof of payment for enrollment in Medicare, another state’s Medicaid program, or another Texas state agency program (The check, money order, or cashier's check must be payable for the [amount] to TMHP.)
• Providers that are incorporated in Texas must submit the following:
• Franchise Tax Account Status Page or IRS 501(c)(3) Exemption Letter
• Corporate Board of Directors Resolution Form (must be notarized)
• Certificate of Formation and Certificate of Filing or Certificate of Authority
• Articles or Certification of Incorporation or Certificate of Fact
• Providers that are incorporated out-of-state must submit the following:
• Certification of Registration or Certificate of Authority
• Franchise Tax Account Status Page or IRS 501(c)(3) Exemption Letter
• Corporate Board of Directors Resolution Form (must be notarized)
• Out-of-state providers must submit proof that they meet one of the following criteria:
• A medical emergency is documented by the attending physician or another provider.
• The client’s health would be endangered if he or she traveled to Texas.
• The necessary medical services are more readily available in the state where the client is located.
• The customary or general practice for clients in a particular locality is to use the medical resources in another other state.
• The services are provided to adopted children who receiving adoption subsidies.
• The services are medically necessary and providers of these services are limited or not readily available in Texas.
• The services are medically necessary services to one or more dually eligible recipients (clients who are enrolled in both Medicare and Medicaid).
• The services are medically necessary and one or more of the following exceptions for good cause exist and are documented:
• Texas Medicaid providers rely on the services provided by the applicant.
• Applicant maintains existing agreements as a participating provider in one or more Medicaid managed care organizations and the enrollment of the applicant leads to more cost-effective delivery of Medicaid services.
• Providers that have experienced a change of ownership must submit the following:
• Bill of Sale
• Change of Ownership Questionnaire and Statement
• Franchise Tax Account Status Page or IRS 501(c)(3) Exemption Letter
• Corporate Board of Directors Resolution Form (must be notarized)
• Medicare Letter acknowledging the Change of Ownership (if applicable)