There are three basic parts to submitting an application:
- Determine your application type
- Submit an application
- Complete the process
Learn more about each part below.
Your application type will determine how Texas Medicaid & Healthcare Partnership (TMHP) will process your application.
A new enrollment is when a provider has never been enrolled, and is enrolling for the first time.
A re-enrollment is when a provider submits an enrollment application after being disenrolled, terminated, excluded or otherwise removed as a provider; meaning the provider’s or supplier’s billing privileges are terminated. The provider will receive the same risk category assignment and go through the same provider screening activities as a newly enrolling provider.
For example, providers would have to re-enroll if they:
- Were disenrolled because they had no claim activity for 24 months
- Were previously excluded or terminated from Medicare or any state Medicaid or the Children’s Health Insurance Program
- Did not submit a revalidation application that was received before the end of their enrollment period
The ACA requires providers to submit a revalidation application at the end of their enrollment period. Most providers have an enrollment period of five years. Some providers have shorter enrollment periods (e.g., 1 year, 2 years). Providers can find the effective dates of their enrollment period within PEMS and on their Provider Welcome letter.
Providers should submit their revalidation applications at least 90 days before the end of their enrollment period so that it can be processed before the enrollment period ends. If a provider does not complete the revalidation process before the end of the provider's enrollment period, there will be a gap in the provider’s Medicaid enrollment.
- If the provider’s enrollment period ends before the provider completes the revalidation process, the provider will not be reimbursed for services rendered from the day after the enrollment period ends until the day on which the provider successfully completes the revalidation process. The provider is responsible for appealing any claims that were denied during that period of time.
- If a provider’s enrollment period ends before the provider’s revalidation application has been received, the provider is automatically disenrolled the day after the enrollment period ends. The provider must then submit a new enrollment application and forfeits the ability to utilize the streamlined revalidation application process. The provider will not be reimbursed for services that are rendered from the day after the enrollment period ends until the day on which the provider successfully completes the re-enrollment process.
The Provider Enrollment and Management System (PEMS) is an electronic application that will guide you through the process of enrolling in Texas Medicaid and other State Health-Care programs. PEMS provides immediate feedback on your application so that you can address issues before submitting your application.
For a step-by-step guide to the Provider Enrollment and Management System, visit the PEMS Instructional Site.
TMHP is committed to assisting providers with enrollment in the Texas Medicaid program and other State Health-Care programs. Computer Based Training (CBT) and other resources to assist with this process are available in the Enrollment Help section of this site. You may also find the following resources helpful when preparing and completing the enrollment process with TMHP:
Once an application has been submitted, it will be reviewed by a Provider Enrollment Specialist. If any deficiencies are identified within the application, Provider Enrollment will request the required corrections.
After the application has been determined to be free of all deficiencies, it may require additional review, such as a site visit or an approval from HHSC.
Once all required approvals have been obtained, the application will be finalized and you will receive a notification letter confirming the completion of the application; it will notify you of your next revalidation date.
If any of your information changes before your revalidation date, you must update your enrollment record by submitting a Maintenance request through the Provider Enrollment and Management System (PEMS).
Important: You must complete the revalidation process by the deadline. If you don’t complete the revalidation process by the deadline, you will be disenrolled from all Texas health care programs and your claims and prior authorization requests will be denied. You must submit a re-enrollment application, and you won’t be able to submit claims or prior authorization requests during the re-enrollment process.