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Provider Enrollment

Everything you need to know to enroll in Texas Medicaid and other State health-care programs.

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How to Apply for Enrollment

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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. 

New Enrollment

A new enrollment is when a provider has never been enrolled, and is enrolling for the first time.

Re-Enrollment

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

Revalidation

Revalidation is the process used to renew an existing enrollment for a provider that is already enrolled in the Provider Enrollment and Management System (PEMS). 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.

Revalidation must be completed before the end of the provider’s enrollment period to avoid a gap in enrollment. Providers are encouraged to submit their revalidation application up to 180 days before the end of their enrollment period to allow enough time for reviews and processing.

Important:

  • Revalidation is not complete until all deficiencies have been corrected, all required reviews have been completed, and the application has reached Closed–Enrolled status on the Requests page in PEMS.
  • Revalidation requests submitted before the revalidation due date that reach Closed–Enrolled status within a 45-day grace period after the revalidation due date are considered completed and will not experience a gap in enrollment.
  • Providers who do not submit a revalidation application before their revalidation due date or whose revalidation request does not reach Closed–Enrolled status within the grace period will be disenrolled from all Texas state health care programs, including Medicaid managed care organizations (MCOs) and dental maintenance organizations (DMOs). Disenrolled providers will have claims and prior authorization requests denied and must submit a reenrollment application to regain participation.

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.