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Application Fee

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Instructions for submitting the Application Fee

Select the Application Type from the left navigation menu.

In accordance with ACA and Title 42 CFR 455.460, certain institutional providers are subject to an application fee for all applications, including, but not limited to:

Initial applications for new enrollment.

Applications for a new practice location.

Applications received in response to reenrollment.

Applications received for revalidation of the provider's enrollment record.

An application fee is not required and will not be accepted if the provider is enrolled in Medicare, another state’s Medicaid program, or another Texas state agency.

For providers who are not required to pay the application fee or provide proof of reciept, you will not be required to answer any of the questions and may move on from this page.

I Am Not Using a Medicare Number for This Enrollment

Instructions: If you are not using a Medicare certification number for this enrollment, select ONE of the following:

I am submitting the application fee to Texas Medicaid by paper check, money order or cashier's check with this application.

 If you select this option, you must provide a copy of the application fee check, money order, or cashier’s check to TMHP. Make the check or money order payable in the appropriate amount for the current fiscal year.

 Click Print the PEMS Cover Letter to access the application fee cover letter that you must submit with your application fee. Ensure that the PEMS Request Number from the top of the PEMS application is written on the application fee check or money order.  

Mail the application fee cover letter and check or money order to:

Texas Medicaid and Healthcare Partnership

ATTN: Provider Enrollment

PO Box 200795

Austin, TX 78720-0795

I attest that I have already paid the application fee to another state's Medicaid program or CHIP program, and I have been approved for enrollment in another state's Medicaid program or CHIP program.

I am requesting an application fee waiver due to financial hardship. My documentation that supports my request is attached to this application.

(If you select this option, you must submit a letter (and supporting documentation) with your enrollment application that details the reason(s) you are unable to pay an application fee.

The supporting documentation may include but is not limited to historical cost reports, recent financial reports such as balance sheets and income statements, cash flow statements, tax returns, etc.

Texas Medicaid does not accept hardship waivers from other state Medicaid programs. Hardship waivers will require state & federal approval of the supporting documentation. If the waiver request is denied, you must submit an application fee if you wish to proceed with the Texas Medicaid enrollment process.)

Click “Save”

Once complete, Access the left navigation and select the next available page to continue entering your application.

The Application Fee section is Not required when enrolling as a Performing Provider.

The Application Fee section is Not required when enrolling as an Ordering- or Referring-Only provider.