Ownership/Controlling Interest Information

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Instructions for completing the Ownership/Controlling Interest Information.

Instructions for updating the Maintenance Ownership/Controlling Interest Page

Note: Only Respite Provider Types that are enrolling as a Facility are required to complete this page.

Note: This provider type does not require this page to be completed. Please proceed to the next page.

Select the Application Type from the left navigation menu.

All providers must complete the Ownership & Controlling Interest section except for “Performing Only” providers who are reassigning all benefits to one or more Organizations that are already enrolled in Texas Medicaid or other state healthcare programs since this information will be captured as part of the enrollment record for the Organization receiving the benefits.

If you require updates to the provider’s ownership information, follow the directions listed for each section.

If you require updates to the "Owners/Creditors/Principals" information, skip to the " Owners/Creditors/Principals" section.

All providers must complete the "Ownership & Controlling Interest" section. Exception: Perfuming Only; providers who are reassigning all benefits to one or more organizations that are already enrolled in Texas Medicaid or other state healthcare programs. This information will be captured as part of the enrollment record for the organization receiving the benefits.

Every person with 5% or more ownership in the entity must answer “Yes” or “No” as it pertains to the Enrolled NPI for each of questions included in the Ownership/Controlling Interest section of PEMS.

Section: Controlling Interest

Do you currently have a creditor with a security interest in a debt that is owed by you? Select Yes or No.

Is the creditor(s) security interest protected by at least 5 percent of your property? Click Yes or No.

If you select "Yes," the following section will appear:

Creditors–This table is be uneditable; skip to step 4.

Name/Company Name

SSN/Tax ID

Date of Birth

Relationship End Date

Driver’s License or Other Number

Percent Owned

Fingerprint Required

Click Add Creditors. Refer to the "Owner/Creditors/Principals" section for instructions on adding creditor’s information.

Section: Ownership

Ownership interest–A direct or indirect ownership interest (or any combination thereof) of five percent or more in the equity in the capital, stock, profits, or other assets of a person or any mortgage, deed, trust, Note, or other obligation secured in whole or in part by the person's property or assets.

Person–Any legally cognizable entity, including an individual, firm, association, partnership, limited partnership, corporation, agency, institution, MCO, Special Investigative Unit, CHIP participant, trust, non-profit organization, special-purpose corporation, limited liability company, professional entity, professional association, professional corporation, accountable care organization, or other organization or legal entity.

Change of Ownership– A change of ownership related to a partnership, sole proprietorship, corporation, or leasing arrangement as defined in 42 CFR §489.18.

Has there been any changes of ownership or control within the past 5 years as defined in 42 CFR §489.18? Click Yes or No.

If you selected "Yes," provide the following details:

Change of Ownership Date.

1. If Medicare approved, the date that is on your Change of Ownership Medicare letter.

If non-Medicare enrolled, the date the ownership was changed.

Entity Name–Name of entity which ownership was acquired.

Explanation of details pertaining to the Change of Ownership.

Was the change of ownership timely reported to CMS? Select Yes or No

If you selected "Yes," provide the date reported.

If you selected "No," provide an explanation why this was not timely reported to Centers for Medicare & Medicaid Services (CMS).

Was the change of ownership reported to Texas Medicaid & Healthcare Partnership within 30 days? Click Yes or No.

If you selected "No," provide an explanation why this was not reported to TMHP within the allotted timeframe.

What person and/or entity is now responsible for Liabilities incurred prior to the change of ownership? Click Yes or No.

Enter the name of the responsible party for liabilities prior to the change of ownership.

Did the applicant use an “asset purchase agreement” to secure any assets from another current and/or former provider? Click Yes or No.

1. If you selected "Yes," provide the following information:

a. Provider Name—Enter the provider name from which you received assets.

b.  NPI Number—Enter the National Provider Identifier from the provider from which you received assets.

c.  Date of Sale—Enter the date of sale.

Provide the documents establishing the assumption of liabilities.

Are you seeking enrollment or updating your enrollment due to a change of ownership? Select Yes or No.

If you selected "Yes," provide the following details:

Did CMS consider this a change of ownership? Select Yes or No

Effective Date – Enter the effective date of the CHOW

Change in Ownership Reason – Select the reason for the CHOW

Current Fiscal Year End Date – Enter the current Fiscal Year end date

Next Fiscal Year End Date – Enter the next Fiscal Year end date

Please list all the provider(s) and practice locations(s) that were purchased by completing the following details:

Seller NPI Number – Enter the seller/previous owner’s NPI number

Seller Contact Name – Enter the seller/previous owner’s contact name

Seller Contact Phone Number – Enter the seller/previous owner’s phone number

Practice Location – Select the seller/previous owner’s practice location that is part of the purchase

Do you assume liability? – Select Yes or No or Not Enrolled

If you wish to add more than one location, then click Add Location to complete the Seller details again and select the practice location

Note: You may add the same seller NPI with the additional location being purchased or a different seller’s NPI if the location to be added is previously owned by a different seller.

If you wish to remove a location, then click Remove Location. This removes all location details previously provided.

If you selected “Yes,” to the above question “Did CMS consider this a change of ownership?” then you will be required to answer the following question:

Was the Seller's Medicare Number(s) retained or retired as part of the purchase?

Retained Sellers Medicare number(s) – Select the Medicare number(s) that the Buyer intends to retain as part of the change of ownership

Retired Sellers Medicare number(s) – select the Medicare number(s) that are being retired as part of the change of ownership

Do you anticipate any change of ownership or control within the year? Click Yes or No.

If you selected "Yes," provide the date for the anticipated change in ownership.

Do you anticipate filing bankruptcy within the year? Click Yes or No.

If you selected "Yes," provide the date of anticipated bankruptcy filing.

Did any former owner(s) transfer their ownership interest to an “immediate family member,” as that term is defined in 42 USC 1320a-7, following a sanction, conviction, licensure restriction of any kind, or assessment of a monetary penalty (civil or criminal)? Click Yes or No.

If you selected "Yes," provide the following information:

First Name—Enter the first name of the former owner.

Middle Initial—Enter the middle initial of the former owner.

Last Name—Enter the Last name of the former owner.

Explanation—Provide an explanation of the disclosure for the former owner.

Did any former owner(s) transfer their ownership interest to an “immediate family member,” as that term is defined in 42 USC 1320a-7, following a sanction, conviction, licensure restriction of any kind, or assessment of a monetary penalty (civil or criminal)? Click Yes or No.

If Yes is selected, provide the following information:

First Name

Middle Initial

Last Name

Explanation

Are any of the new owners related to any of the former owners as defined above? Select Yes or No.

If "Yes" please disclose any of the above familial relationships between owners and/or the provider.

Former Owner Name - Enter the full name of the Former Owner.

Current Owner Name - Enter the full name of the Current Owner.

Relationship - Enter the relationship between the Old and New Owners.

Click Add Relationship to save this information.

Repeat as necessary.

Section: Management

Does the provider comprise or include a facility that is operated by a management company, or a facility that is leased in whole or in part by another organization? Select Yes or No.

If "Yes", give the date of change in operations.

Section: Staffing

Has there been a change in Administrator, Director of Nursing or Medical Director within the last year? Select Yes or No.

Section: Principals

Has there been a change in any principals within the last year? Click Yes or No.

If Yes, provide the following:

Date—Enter the date of.

Name (First and Last Name)—Enter the first and last name of the principal(s).

Explanation—Provide an explanation of the change in principal(s).

Did any former principals leave the provider following a sanction, conviction, licensure restriction of any kind, or assessment of a monetary penalty (civil or criminal)? Click Yes or No.

If Yes, provide the following:

Date—Enter the date of.

Name (First and Last Name)—Enter the first and last name of the principal(s).

Explanation—Provide an explanation of the change in principal(s).

Did any former principals leave the provider in anticipation of or with knowledge of a pending administrative, civil and/or criminal investigation that could possibly result in a sanction, conviction, professional licensure restriction of any kind, or assessment of a monetary penalty (civil or criminal)? Click Yes or No.

If Yes, provide the following:

Date—Enter the date of.

Name (First and Last Name)—Enter the first and last name of the principal(s).

Explanation—Provide an explanation of the change in principal(s).

Are there or have there been any individuals or organizations having a direct or indirect ownership or control interest of five percent or more in the institution, organizations, or agency that have been sanctioned related to the involvement of such persons, or organizations, in any of the programs established by Titles XVIII, XIX, or XX? Click Yes or No.

If Yes, provide the following:

Date—Enter the date of.

Name (First and Last Name)—Enter the first and last name of the principal(s).

Explanation—Provide an explanation of the change in principal(s).

Are there or have there been any individuals having a direct or indirect ownership or control interest of five percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations, in any of the programs established by Titles XVIII, XIX, or XX? Click Yes or No.

If Yes, provide the following:

Date—Enter the date of.

Name (First and Last Name)—Enter the first and last name of the principal(s).

Explanation—Provide an explanation of the change in principal(s).

Does the provider comprise or include a facility that is operated by a management company, or a facility that is leased in whole or in part by another organization? Click Yes or No.

If Yes, provide the following:

Date:

Explanation

Name (First and Last Name)

Explanation

Section: Affiliation

Is the provider identified chain affiliated? Click Yes or No.

Chain Name—Enter the Name of the chain.

EIN Number—Enter the EIN number.

Street Address 1—Enter the street address.

Street Address 2—Enter the suite or building number (if applicable).

City —Enter the city.

State—Enter the state.

ZIP Code—Enter the ZIP Code.

Zip Code +4—Enter the ZIP +4.

Section: Owners/Creditors/Principals

Modifying an Existing Owner/Creditor/Principal.

PEMS will present all owners, creditors, and principals in table view.

Click the ellipsis (…) icon for the appropriate owner, creditor, or principal, and then click Open to edit the details.

Alternatively, click Delete to remove an owner, creditor, or principal.

If you need to add a new principal to the "Owners/Creditors/Principals" table, proceed with the next steps:

Adding a New Owner, Creditor or Principal.

1. Click Add Owner/Creditor/Principal.

2.  Before manually entering all the information required to add a new owner, creditor, or principal, use the Social Security Number (SSN) or Tax ID Lookup to identify whether or not the person or entity already exists in PEMS.

Enter the SSN for people, or Tax ID number for entities.

 Click Verify Information.

If a match is found, verify that the person or entity found is accurate by reviewing that the last name of the person or company name tied to the SSN/EIN number is correct.

If the wrong person or entity was located, click try searching again.

If the correct person or entity was located, click Continue.

3.  Complete the "Owner/Creditor/Principal Information" sub-pages.

4.  Repeat for each person or entity who meets the definition of principal or subcontractor.

Note: If you need to modify the SSN/EIN of an owner, creditor or principal, you must remove that person or entity from the "Owners/Creditors/Principals" list and reenter the person or entity’s information with the correct information.

Instructions for completing the Owner/Creditor/Principal Information sub-page.

Section: Basic Information

Click Person or Entity.

Click Principal or Subcontractor

What is the percentage of ownership? Enter the percentage of the provider that is owned by the person or entity.

Basic Information - Entity

 This section is not required for owners/creditors/principals that are persons.

Owner’s Name (as shown on your income tax return)—Enter the name of the owner, creditor or principal entity.

Do you conduct business under an assumed name? Select Yes or No.

• If "Yes", enter the name.

Taxpayer Identification Number (TIN)—Enter the TIN of the entity owner.

How is the entity organized to conduct business or activities?—Select the type of entity from the selections below.

If you selected Other, please provide the Tax Classification below.

Basic Information - Person

This section is not required for owners/creditors/principals that are entities.

Complete the “First Name” and “Last Name” fields.

Complete the “Middle Name” field if you have one.

 Select your gender from the "Gender" drop-down menu

Complete the “Date of Birth” field.

Complete the “Social Security Number (SSN)” field.

Complete the “Driver’s License or Other Number” field.

• If your driver’s license is expired or you do not have one, you can enter the number from any current government-issued photo identification document (ID). The driver’s license or government-issued ID must be valid and unexpired on the date that the request is submitted.
• Examples include:

Texas Identification Card

U.S. passport book or U.S. passport card

U.S. Military ID

Complete the State Issuer – select from the drop-down menu.

Complete the “Driver’s License or Other Number Expiration” field.

Maiden Name, Alias or Nicknames Ever Used

Complete the First, Middle and Last Name fields as it pertains to your situation.

If this person does not have a Maiden, Alias or Nickname, leave blank.

Click Save.

Access the left navigation and select the next available page to continue entering your request.

Section: Addresses

Complete the “Physical Address” fields.

Enter the following:

Address –Line 1—Enter the street address.

 Address – Line 2—if applicable —Enter the suite or apartment number.

City—Enter the city.

State—Select the state from the drop-down menu.

Zip Code—Enter the ZIP Code.

Zip Code +4—Enter the ZIP Code +4.

Click "Verify Address".

If the address verification fails and you entered the address correctly, select the “accept address” checkbox to accept the address as it is written.

Select the checkbox “Click to change address” in order to make edits to the existing address.

Complete the “Accounting/Billing Address” fields.

Complete the “Accounting/Billing Address” fields (if applicable).

If the Accounting/Billing Address is the same as the physical address, select the box. : If not, enter the following:

Address – Line 1

Address – Line 2, if applicable

City

State: Select from the drop-down menu

Zip Code

Zip Code +4

Address – Line 1; if applicable - Enter the Suite Number or Apt Number

Address – Line 2; if applicable - Enter the Suite Number or Apt Number

City - Enter the City

State: select from the drop-down menu.

Zip Code - Enter the Zip Code

Zip Code +4 - Enter the Zip +4

Click Verify Address.

If the address verification fails and you entered the address correctly, select the “accept address” checkbox to accept the address as it is written.

Click Save.

Access the left navigation and select the next available page to continue entering your request.

Click Save.

Access the left navigation and select the next available page to continue entering your request.

Section: Licenses & Other Documentation

Select "Yes" or "No" for "Do you have one or more professional licenses, accreditations or certifications?"

If you selected Yes, click Add Professional License/Certification/Accreditation

Select the “Type” from the drop-menu.

Complete the “Issuer” field.

Complete the “Number” field.

Select the state from the “State” drop-down menu. 

Complete the “Issue Date” field.

Complete the “Expiration Date” field.

Repeat to provide each of your professional health-care licenses, accreditations and certifications.

Click Save.

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

Section: Employment Information

You must answer Yes or No as it pertains to any employment information you have or had with any other provider.

Complete the “Your title in the provider organization for for which enrollment is being sought" field.

Note: Pharmacy providers must have a Pharmacist in Charge.

Complete the "Your duties to the provider organization" field.

List the duties (tasks or actions that you are required to perform) that you perform for the provider organization.

Select a role from the “Your role in the provider organization” list and complete the "Effective Date" field.

Do you have employment history with a separate provider?  Select Yes or No.

If you selected "Yes, list each of the medical entities with whom you have an employment history with and, if known, the NPI/API of each entity (as applicable).

Complete the NPI, Provider Name, Address, City, State, Effective Start and End Date for the employment history.

Select Add employment history for all applicable contractual relationships you have.

Click Save.

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

Section: Relationship Information

You must answer Yes or No as it pertains to any contractual relationships you have with any other providers.

1. Do you have a relationship with a separate provider? Click Yes or No.

 If "Yes," list each of the medical entities with whom you have a contractual relationship and, if known, the National Provider Identifier (NPI) or Atypical Provider Identifier (API)of each entity (if applicable).

NPI

Provider Name

Address (Number, Street, and Apt or Suite Number)

City

State

City

Start Date

End Date: Enter only if you are adding an end date to an existing relationship.

2.  Click Save.

3. Repeat as necessary.

Section: Disclosures

You must answer “Yes” or “No” as it pertains to the Principal for each of the questions below. Your answers should address all past and current actions as applicable.

“Sanction” is defined as recoupment, payment hold, imposition of penalties or damages, contract cancellations, exclusion, debarment, suspension, revocation, or any other synonymous action.

Make a selection from the drop-down menu in order to associate each attachment to a question. If you have attachments that you have added to the page, select the drop-down menu to associate each attachment to the corresponding question.

If you selected "Yes,” you must explain the details in the additional field provided below the question. Your explanation must include the details of how past-due obligations will be met.

Attach all relevant documentation for the proof of compliance to repayment, along with a payment plan, to the page. If unable to provide documentation, explain why and where it can be obtained.

Click Save.

Once all of the subpages have been completed, use the left navigation arrow in the blue header to return to the main age navigation. Then select the next available page to continue entering your application.

Once all subpages have been completed, use the left navigation arrow in the blue header to return to the main page navigation. Repeat steps for each Owner/Creditor/Principal.

Section: Designation of Authorized Individual(s)

If you need to navigate away to gather more information prior to submission, select Save Draft to save progress and come back when you are ready to submit your changes.

1. Click Add Authorized Signatory.

2. Select the Principal to designate the Authorized Signatory from the drop-down menu.

The title should populate from the Employment page for this principal.

3. Enter the email address for the Authorized Individual.

This email will be used to notify the Authorized Individual when selected to E-sign the HHSC Provider Agreement.

4. Click Save changes.

5. Repeat if necessary.

6. If you wish to remove an Authorized Signatory, select the ellipse (…) and select Delete.

A pop-up will ask if you are sure you want to delete this signatory. If yes, click OK.

7. If you wish to edit an existing Authorized Signatory, select the ellipse (…) and select Edit.

You can only edit the email address for this Authorized person.

8. Once complete, click Save.

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