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Practice Location Information

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Instructions for completing the Practice Location Page

Instructions on updating the Practice Location Page

Instructions for Reviewing the Practice Location Page

Select the Application Type from the left navigation menu.

For each new practice location, click Add New Practice Location to add each address at which you render services.

Verify the information for the location that is already on file. To many any updates to the information on file, click the ellipses (…) icon and then click Open.

Note: Use the left navigation arrow in the blue header to return to the main page navigation. After you click Add New Practice Location, an “Add Practice” modal will display and require selection of the type of Location:

Facility: This type of enrollment applies to situations in which licensure or certification applies to the entity. Although individuals working for or with the entity may be licensed or certified in their individual capacity, the enrollment is based on the licensure or certification of the entity.

Group: This type of enrollment applies to health-care items or services provided under the auspices of a legal entity, such as a partnership, corporation, limited liability company, or professional association, and the individuals providing health-care items or services are required to be certified or licensed in Texas. The enrollment is under the name and federal tax identification number of the legal entity.

Note: After the group is approved, there must be at least one performing provider associated to the group.

Section: Basic Information

Verify the information on file. If you require changes to any of the information below, continue through the next steps:

Confirm or update the required information for your practice location at which you render healthcare services or base of operations for mobile services.

Confirm or update the information labeled as “optional” as it pertains to your situation.

Note: If the address requires corrections or changes and is greyed out, click the “Click to change address” checkbox to make edits.

Location Name (Optional–This name will appear in the practice locations table for each address associated to your enrollment record for quick reference)

Address Line 1

Address Line 2 (Optional–for Suite Number or Apartment Number)

City

State

For providers that are out-of-state providers:

If your practice location is 50 miles outside from the Texas border, you must submit additional documentation according to Texas Administrative Code TAC § 352.17.

This can be attached below by clicking the “Click here to select files” button.

Zip Code

Zip Code +4 (optional - PEMS will look up this number according to U.S. Postal Service data when you click "Verify Address")

Click Verify Address.

Verify that the address that you entered matches the address where services are rendered to clients. You must not enter the accounting, corporate, or mailing address information as the "Practice Location"; you can provide the information as "Additional Address(es)" associated to each practice location as applicable.

If the address verification shows an error and the practice location entered is accurate, click Continue with address entered.

Bad Address Indicator

This section will hold the Bad Address Indicator and effective date. The Bad Address indicator is when TMHP receives return mail from the USPS, which will result in the indicator being set. When the provider has this indicator set, the provider will not be able to receive payments until they submit a Maintenance request confirming the Physical Address is valid and correct. After TMHP validates the request and it is approved, TMHP will remove the indicator.

This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

Phone Number

Extension (Optional–This information will appear in the Online Provider Lookup)

Fax Number (Optional–This information will appear in the Online Provider Lookup)

Effective Date – This will be the effective date of this practice location. This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

End Date – This will be the end date for this practice location. This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

End Reason – The reason for this practice location to be end dated will be entered in this field. This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

Section Practice Location Address Record History

This will contain the previous address information that was on the enrollment record for the National Provider Identifier (NPI) that has since been end dated as a practice location. This information will be blank and uneditable for new enrollments.

Location Name

Address

Effective dates

Once you have verified your address information, click “Save”.

When you have completed your updates, click Submit All Changes

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

Section: Programs and Services Participation Details

Click the +Add Program and Service Participation button. This will navigate to the "Program Participation" section.

Section: Program Participation

Verify the information on file. If you require changes to any of the information below, continue through the next steps:

Select the State Health-Care Program Service (or Services) you will be associating to your practice location using the “Select a Program” drop-down menu. You may select more than one option.

Section: Status Codes 

The following section will display any current status codes that affect your enrollment record. This information will be blank and uneditable for new enrollments.

Type—Type of status code

Description—Description of status code

Effective Dates—Effective date of status code

Section: Service Provided

Provide the following information:

Primary Taxonomy—Select the available taxonomy code from the drop-down menu.

Provider Type—Select the available provider type description from the drop-down menu.

After selecting the provider type, the next item will appear:

Internal Provider Type—Select the available Internal Provider Type description from the drop-down menu.

After selecting the internal provider type, the next item will appear:

Specialty—Select the available specialty description from the drop-down menu.

After selecting the specialty, the next item will appear (if applicable):

Sub-Specialty—Select the available subspecialty description from the drop-down menu.

Section: Add Licenses / Certifications / Accreditations

Verify the information already. If you have an additional license, certification or accreditation to add, follow the directions below:

Click +Association License/Certification/Accreditation. This will pop-up the "Add Licenses/Certifications /Accreditations" modal.

Click the "License/Certification/Accreditation" from the drop-down menu. 

This list is prepopulated from the licenses, certifications, or accreditations entered earlier in the application.

If you do not see your license represented in this drop-down menu, you must go back to the "Licenses/Certification/Accreditation" page to add it

Section: Tax Number

Select the Tax Number from the drop-down menu (prepopulated from the W9 form).

Below will be the Tax History for any changes to the Tax Number from previous enrollment updates. This information will be greyed out as view only data.

Section Reassignment of Benefits History

*For performing providers only This will show the association of your enrollment to the corresponding group enrollment in this table.

Section Program-Specific Questions

The following section will have program-specific questions for the enrolling provider to complete for each program selected above.

For KHC providers, the Medicare Information in your Acute Care enrollment record will be displayed below in the Alternate Identifiers section after your enrollment is approved.

Are you using a Medicare Certification Number for this location? Click Yes or No.

If you select Yes, you will complete the following:

Select the “Add Medicare Number” button. The following will appear:

Medicare Number

Medicare Effective Date

Medicare End Date

If you select No, the following checkboxes will appear and will be required to be selected:

"I understand that the services that are provided to Medicare-eligible clients cannot be billed to Medicaid unless Medicare is billed first. If the services are not billed to Medicare first, Medicaid may recoup payments for the services. I also understand that I cannot bill the client for these services.”: Check the box to acknowledge this statement.

Medicare Waiver Request: You must select one of the following requests for enrolling without Medicare, if your enrollment type has Medicare as a pre-requisite:

I certify my practice is limited to individuals’ birth through 20 years of age. I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. - Select this if the services you provide are for Pediatric services for individuals age 0 through 20.

I certify that the service(s) I render is /are not recognized by Medicare for reimbursement. I further certify the claims for these services will not be billed to Medicare (this includes Medicare crossover claims). I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. - Select this if the services you provide are for clients of all ages.

In the box below the checkboxes, you will have to provide an explanation to justify your reasons for making a Medicare Waiver Request.

Medicare Information will be provided by your acute care enrollment. It will be displayed in the Alternate Identifiers section below.

Current Fiscal Year End: Enter your Current Fiscal “End Date.”

Medicare Intermediary: (The name and address where you send your Medicare cost report)

Name:

Address Line 1

Address Line 2

City

State

Zip Code

Zip Code+4

Phone Number

Ext

Contact for cost report information: (At facility)

Name:

Phone Number

Ext

Do you offer Telehealth services? – Select Yes or No

Do you offer Telemedicine services? – Select Yes or No

Do you want to be a limited provider? – Select Yes or No.

Select Yes if you wish to see clients that are considered high risk

Do you provide hearing services for children? – Select Yes or No

Note, if you are not providing hearing aid services, you may select No.

Are you an Urgent Care Center? – Select Yes or No

Note, if you are not enrolling into an Urgent Care Center, you may select No

Section: Kidney Health Care

Verify the information on file. If you require changes to any of the information below, make the appropriate edits as needed.

Select the answers to the following questions as it pertains to your enrollment:

Number of Dialysis Stations—Enter the number of stations for each type.

Select from: Hemodialysis; CAPD; CCPD; IPD

Training Provided—Select the type of training provided to your staff; it should match the selection above for the number of dialysis stations.

Select from: Self-Hemo (In-Center); Home Hemodialysis; CAPD; CCPD

Enter the following information for RRC (Ratio of Cost to Charges):

Inpatient RRC Ratio

Inpatient RRC Effective Date

Outpatient RRC Ratio

Outpatient RRC Effective Date

Section: Pharmacy Services

If you wish to opt out of enrollment into the following Pharmacy Services Subprograms, make your selection here:

CHIP

CSHCN

HTW

KHC

Note: You will not be reimbursed for services for which you have opted out.

Provide a response for each of the following pharmacy-specific questions:

Source of Purchase Information

Indicate your sources for purchase of pharmaceutical products by answering the following questions:

Primary Wholesaler—Type the full name of your pharmacy’s primary wholesaler.

Secondary Wholesaler—Type the full name of your pharmacy’s secondary wholesaler.

Percent direct purchased from manufacturer—Enter the percent direct purchased from the manufacturer.

Co-Op or Buying Group—Enter the name of your co-operative or buying group.

List companies with whom you have direct accounts—Enter the full name of the companies with whom you have direct accounts.

Is your pharmacy eligible as a Public Health Entity Buy (subsection 340B Veteran’s Health Care Act 1992)?—Answer Yes or No.

For more information about Public Health Service, visit hrsa.gov/opa. For more information about the 340B program in Texas Medicaid, visit www.txvendordrug.com/providers/340b-providers.

For Chain Pharmacies: How many pharmacies do you have?—Identify how many pharmacies make up a chain both instate Texas and within the United States.

Do you have a warehouse?—Answer Yes or No. to whether the pharmacy has a warehouse.

Do you have an agreement with your wholesaler to house or store the drugs for you?—Answer Yes or No.

If "Yes," identify who owns the product while stored. Choose either Pharmacy or Wholesaler.

Do you have one contract or agreement with the wholesaler to serve all of your locations?—Answer Yes or No.

Do you allow your pharmacies to make spot purchases outside of the existing wholesaler contract/agreement?—Answer yes or no.

Is the pharmacy located within a Hospital?—Answer Yes or No.

If "Yes," provide the name of the hospital and a letter detailing what type of services provided and recipients served.

Is the pharmacy located within a medical clinic?—Answer Yes or No.

If "Yes," provide the name of the medical clinic and a letter detailing what type of services provided and recipients served.

Is the pharmacy located within an MHMR Hospital clinic?—Answer Yes or No.

If "Yes," provide the name of the MHMR Hospital Clinic and a letter detailing what type of services provided and recipients served.

Is the pharmacy a central fill location?—Answer Yes or No.

If "Yes," provide the name of host pharmacy.

Is the pharmacy a remote fill location?—Answer Yes or No.

Is this a closed-door pharmacy?—Answer Yes or No.

If "Yes," provide a letter detailing what type of services provided and recipients served.

Does this pharmacy exclusively dispense to a type of customer (e.g. home health care recipients, or patients with a specific chronic condition?—Answer Yes or No.

If "Yes," provide a letter detailing what type of services provided and recipients served.

Does this pharmacy receive public funds other than Medicaid and Medicare?—Answer Yes or No.

If "Yes," provide name of payers and percentages.

Choose one from the following criteria that applies to this enrollment:

A.) Does the pharmacy meet all the following criteria?

(1) The expected total Medicaid claims for specialty drugs (as described in 1 TAC Section 354.1853), exceeds or would exceed 10 percent of the pharmacy's total Medicaid claims per year;

(2) The pharmacy obtains or is expected to obtain volume-based discounts or rebates on specialty drugs from manufacturers or wholesalers;

(3) The pharmacy delivers or is expected to deliver at least 80 percent of dispensed prescriptions by shipment through the U.S. Postal Service or other common carrier to customers or healthcare professionals including physicians and home health providers.

B.) Does the pharmacy meet the following criteria?

(1) The expected total Medicaid claims for prescription drugs to residents of long-term care facilities exceeds or would exceed 50 percent of the pharmacy's total Medicaid claims per year.

C.) Does the pharmacy operate as a community retail facility, e.g., an independent pharmacy, a supermarket pharmacy, a chain pharmacy or a mass merchandiser pharmacy having a state license to dispense medications to the public?

Who is your software company for the online submission of pharmacy claims?—Provide the name of your software company.

What company serves as your switch service bureau? If unknown, contact your software company.—Provide the name of the company.

What are the days of the week and the hours of operation for the pharmacy (e.g. Mon-Fri, 8:00 a.m. to 5:00 p.m.?)

Is the pharmacy presently open?—Answer Yes or No.

If no, by what date do you expect to open?—Provide a date.

Do you own the building in which your business is located?—Answer Yes or No.

Do you lease the building in which your business is located?—Answer Yes or No.

Are you located in a building including other health care providers authorized to write prescriptions?—Answer yes or no.

If "Yes," provide the following information:

Name of Individual or Entity

Area code and Telephone number

Address (Street, City, State, and Zip code)

Delivery Incentive: Please answer Yes or No if you wish to participate.

Click Save.

Section: Traditional Medicaid/Acute Care:

Healthy Texas Women Select Yes or No for the attestation for providing Healthy Texas Women (HTW) or HTW Plus services at this location.

Facilities Only

The following questions will require a yes selection based on the type of facility the provider is enrolling as.  Both questions cannot be No.

Is this a freestanding facility? – Select Yes if the facility at this enrollment location is not a part/wing of a Hospital.  Otherwise, select No.

Is this a Hospital-based facility?  - Select Yes if the facility at this enrollment location is a part/wing of a Hospital.  The next section below will appear.

Otherwise, select No.

If you selected Hospital above, answer the following

Indicate the type of hospital facility below:

Children 

Teaching Facility  

Long Term 

Short Term

Private Full Care

Private Outpatient 

Psychiatric  

Rehabilitation

State Owned 

What is your average daily room rate? 

Private: 

Semi-private: 

What are the current number of beds within your hospital? Enter the number of total beds 

What is/was the date of construction for your hospital? Enter the estimated date 

Do you have children’s unit(s) within your hospital?  Answer Yes or No 

 Have you increased your bed capacity by 10 percent or more, or by 10 beds? Whichever is greater within the last two years?  

If yes, give year of change:

Prior beds: 

Is this an end stage renal dialysis (ESRD) facility?  - Select Yes if the facility is enrolling as a Chemical Dependency Treatment Facility provider.  Otherwise, select No. 

If Yes, what is your composite rate? – enter the rate 

Are you enrolling as a school district? - Select Yes or No 

If you select Yes, enter your T.E.A. Number 

If you are a public entity, are you required to certify expended funds? - Select Yes or No. 

If Yes, the following fields will be available: 

In Care of Name – Enter the Name of the Public Entity 

Address Line 1 – Enter the Street Address

Address Line 2 – Enter the Suite Number or Building Number (If Applicable) 

City – Enter the City

Zip Code – Enter the Zip Code 

Zip Code +4 – Enter the +4 for the Zip Code 

Pharmacy History

This section will be autofilled for applicable providers after enrollment is complete.

Section Alternate Identifiers

This section is only editable to Provider Enrollment staff.

Indicators

This section will be for applicable providers after enrollment is complete.

Click Save.

Repeat as necessary.

Access the left-sided navigation and select the next available page to continue with your application.

Section: Surety Bond

Providers who require a Surety Bond for their enrollment will fill out the bond information below.

Surety Bond Number – Enter the bond number issued by your bond company.

Surety Bond Company Name – Enter the bond company name listed on your surety bond.

Surety Bond amount – Enter the amount as stated on your bond

Note: Surety Amount should equal $50,000 per practice location.

Surety Bond Effective Date – Enter the effective date of your Surety Bond.

The effective date of your Surety Bond cannot be future dated and cannot be more than 1 year in the past from the time you submit your application.  You must submit proof of continuation by submitting a Continuation Certificate issued by your bond.

Surety Bond Expiration Date – Enter the expiration date of your Surety Bond.

This will be 1 year from the effective date of the Surety Bond.

Click Save

Section: Surety Bond History

This section will house your existing Surety Bond information.  *Note, this will be blank for new enrollments and un-editable by the provider and TMHP Provider Enrollment.

Section: Site Visit

If your screen risk category is a Moderate or High, you will require a Site Visit before your enrollment can be finalized.  *Note, this will be blank for new enrollments and will not be editable by the provider or TMHP Provider Enrollment.

Click Save.

Repeat as necessary.

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

Section: Demographics

Verify the information on file. If you require changes to any of the information below, continue through the next steps:

Select the counties you serve in the drop-down menu.

Note: If county restrictions do not exist, you can select "Client Default" rather than add each individual county.

Select answers to Additional Language.

Provide Office hours for each day of the week: add in the open time and closing time for each day of the week.

Click Save.

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

Please complete the following section for addresses that correspond to your situation:

Section: Managing Employees

1.  Click +Add Managing Employee Association. The "Add Employee" modal will appear.

2. Select the managing employee at this location by clicking on the "Selected Employee" drop-down menu.

3.  Select the role of the managing employee by clicking on the "Managing Employee Role" drop-down menu.

4.  Enter the start date at this location.

5. Click Save

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

Section: Mailing/Contact Address

1.Select +Add Mailing/Contact Addresses to add each contact or mailing address associated to your Practice Location.

2. Select the Address Type from the drop-down menu

KHC requires an Address Type of Mailing with a Contact Type of Social Worker.

KHC requires an Address Type of Contact Address with a Contact Type of Enrollment Contact.

3. Enter the Location Name for this address (optional)

4. Enter the address below with the following information:

Street Address 1

Street Address 2: for Suite Number or Apartment Number.

City

State.

Zip Code + 4

Verify the address.

If the address verification shows an error, and the location entered is accurate, select “Continue with address entered.”

Enter the Phone Number & extension

Enter the Fax Number (optional).

5. Contact Information

Select a Contact Type from the drop-down menu.

For KHC Enrollments, you must enter at least one contact type of Social Worker

Enter the first name and last name for the contact at this address.

KHC requires an Contact Type of Social Worker within the Mailing/Contact Address type Mailing Address

KHC requires an Contact Type of Enrollment Contact within the Mailing/Contact Address type Contact Address

6.  Click Save.

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

For each new practice location, click Add New Practice Location to add each address at which you render services.

Verify the information for the location that is already on file. To many any updates to the information on file, click the ellipses (…) icon and then click Open.

Note: Use the left navigation arrow in the blue header to return to the main page navigation. After you click Add New Practice Location, an “Add Practice” modal will display and require selection of the type of Location:

Note: Use the left navigation arrow in the blue header to return to the main page navigation.

Do you bill for services at this location? (Select Yes or No)

If you are a performing provider at this location, click No. The next question will appear after "No" is selected.

Are you a member of a group at this location? Click Yes or No.

If you are a performing provider for a group at this location, click Yes.

If you are not a performing provider nor a billing provider, click No.

A checkbox with the statement “I understand that in the future if I wish to seek reimbursements for services performed to Medicaid recipients, I must submit a new enrollment application to be eligible for Medicaid billing” will appear after "No" is selected.

If you selected Yes to “Are you a member of a group at this location,” the following will appear:

Group NPI—Enter the group’s National Provider Identifier (NPI) for which you are seeking enrollment as a performing provider.

After you enter the NPI, the group’s name will appear to the right of the group’s NPI.

Group Location—Select the location you are enrolling into.

If you answer "No" to "Are you a member of a group at this location?" the following will appear:

You must select the following checkbox: "I understand that in the future if I wish to seek reimbursement for services performed to Medicaid recipients, I must submit a new enrollment application to be eligible for Medicaid Billing."

Note: This checkbox is for enrollment as an ordering/referring provider. If you currently have an existing Medicaid enrollment, by selecting this checkbox, you are voluntarily withdrawing your Medicaid and Children with Special Health Care Needs (CSHCN) Services Program billing provider enrollment to enroll for the sole purpose of ordering/referring. Choose this option only if you will no longer be billing Texas Medicaid .

Section: Basic Information

Verify the information on file. If you require changes to any of the information below, continue through the next steps:

Confirm or update the required information for your practice location at which you render healthcare services or base of operations for mobile services.

Confirm or update the information labeled as “optional” as it pertains to your situation.

Note: If the address requires corrections or changes and is greyed out, click the “Click to change address” checkbox to make edits.

Location Name (Optional–This name will appear in the practice locations table for each address associated to your enrollment record for quick reference)

Address Line 1

Address Line 2 (Optional–for Suite Number or Apartment Number)

City

State

For providers that are out-of-state providers:

If your practice location is 50 miles outside from the Texas border, you must submit additional documentation according to Texas Administrative Code TAC § 352.17.

This can be attached below by clicking the “Click here to select files” button.

Zip Code

Zip Code +4 (optional - PEMS will look up this number according to U.S. Postal Service data when you click "Verify Address")

Click Verify Address.

Verify that the address that you entered matches the address where services are rendered to clients. You must not enter the accounting, corporate, or mailing address information as the "Practice Location"; you can provide the information as "Additional Address(es)" associated to each practice location as applicable.

If the address verification shows an error and the practice location entered is accurate, click Continue with address entered.

Bad Address Indicator

This section will hold the Bad Address Indicator and effective date. The Bad Address indicator is when TMHP receives return mail from the USPS, which will result in the indicator being set. When the provider has this indicator set, the provider will not be able to receive payments until they submit a Maintenance request confirming the Physical Address is valid and correct. After TMHP validates the request and it is approved, TMHP will remove the indicator.

This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

Phone Number

Extension (Optional–This information will appear in the Online Provider Lookup)

Fax Number (Optional–This information will appear in the Online Provider Lookup)

Effective Date – This will be the effective date of this practice location. This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

End Date – This will be the end date for this practice location. This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

End Reason – The reason for this practice location to be end dated will be entered in this field. This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

Section Practice Location Address Record History

This will contain the previous address information that was on the enrollment record for the National Provider Identifier (NPI) that has since been end dated as a practice location. This information will be blank and uneditable for new enrollments.

Location Name

Address

Effective dates.

Once you have verified your address information, click “Save”.

When you have completed your updates, click Submit All Changes

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

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

Section: Programs and Services Participation Details

Click the +Add Program and Service Participation button. This will navigate to the "Program Participation" section.

Section: Program Participation

Select the State Health-Care Program Service (or Services) you will be associating to your practice location using the “Select a Program” drop-down menu. You may select more than one option.

Select the Associated Group’s Program – This is not applicable to providers not enrolling as a Performing Provider.

Do you wish to resume participation? – This will be blank and uneditable for New Enrollments.

Retroactive Claim Date – This will be blank and uneditable for New Enrollments.

Section: Status Codes 

The following section will display any current status codes that affect your enrollment record. This information will be blank and uneditable for new enrollments.

Type—Type of status code

Description—Description of status code

Effective Dates—Effective date of status code

Section: Service Provided

Provide the following information:

Primary Taxonomy—Select the available taxonomy code from the drop-down menu.

Provider Type—Select the available provider type description from the drop-down menu.

After selecting the provider type, the next item will appear:

Internal Provider Type—Select the available Internal Provider Type description from the drop-down menu.

After selecting the internal provider type, the next item will appear:

Specialty—Select the available specialty description from the drop-down menu.

After selecting the specialty, the next item will appear (if applicable):

Sub-Specialty—Select the available subspecialty description from the drop-down menu.

Section: Add Licenses / Certifications / Accreditations

Verify the information already. If you have an additional license, certification or accreditation to add, follow the directions below:

Click +Association License/Certification/Accreditation. This will pop-up the "Add Licenses/Certifications /Accreditations" modal.

Click the "License/Certification/Accreditation" from the drop-down menu. 

This list is prepopulated from the licenses, certifications, or accreditations entered earlier in the application.

If you do not see your license represented in this drop-down menu, you must go back to the "Licenses/Certification/Accreditation" page to add it

Section: Tax Number

Select the Tax Number from the drop-down menu (prepopulated from the W9 form).

Below will be the Tax History for any changes to the Tax Number from previous enrollment updates. This information will be greyed out as view only data.

Section Reassignment of Benefits History

*For performing providers only This will show the association of your enrollment to the corresponding group enrollment in this table.

Section Program-Specific Questions

The following section will have program-specific questions for the enrolling provider to complete for each program selected above.

For KHC providers, the Medicare Information in your Acute Care enrollment record will be displayed below in the Alternate Identifiers section after your enrollment is approved.

Are you using a Medicare Certification Number for this location? Click Yes or No.

If you select Yes, you will complete the following:

Select the “Add Medicare Number” button. The following will appear:

Medicare Number

Medicare Effective Date

Medicare End Date

If you select No, the following checkboxes will appear and will be required to be selected:

"I understand that the services that are provided to Medicare-eligible clients cannot be billed to Medicaid unless Medicare is billed first. If the services are not billed to Medicare first, Medicaid may recoup payments for the services. I also understand that I cannot bill the client for these services.”: Check the box to acknowledge this statement.

Medicare Waiver Request: You must select one of the following requests for enrolling without Medicare, if your enrollment type has Medicare as a pre-requisite:

I certify my practice is limited to individuals’ birth through 20 years of age. I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. - Select this if the services you provide are for Pediatric services for individuals age 0 through 20.

I certify that the service(s) I render is /are not recognized by Medicare for reimbursement. I further certify the claims for these services will not be billed to Medicare (this includes Medicare crossover claims). I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. - Select this if the services you provide are for clients of all ages.

In the box below the checkboxes, you will have to provide an explanation to justify your reasons for making a Medicare Waiver Request.

Medicare Information will be provided by your acute care enrollment. It will be displayed in the Alternate Identifiers section below.

Do you offer Telehealth services? – Select Yes or No

Do you offer Telemedicine services? – Select Yes or No

Do you want to be a limited provider? – Select Yes or No.

Select Yes if you wish to see clients that are considered high risk

Do you provide hearing services for children? – Select Yes or No

Note, if you are not providing hearing aid services, you may select No.

Are you an Urgent Care Center? – Select Yes or No

Note, if you are not enrolling into an Urgent Care Center, you may select No

Referring/Consulting/Supervising Physician

Enter the Referring/Consulting/Supervising Physician's First and Last Name.

Must match the provider's license.

Enter the Referring/Consulting/Supervising Physician's NPI.

Enter the Referring/Consulting/Supervising Physician's License Number

Select the Referring/Consulting/Supervising Physician's License Issuer

Enter the Referring/Consulting/Supervising Physician's License Effective Date

Enter the Referring/Consulting/Supervising Physician's License Expiration Date

Healthy Texas Women Select Yes or No for the attestation for providing Healthy Texas Women (HTW) or HTW Plus services at this location.

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

Section: Surety Bond History

This section will house your existing Surety Bond information.  *Note, this will be blank for new enrollments and un-editable by the provider and TMHP Provider Enrollment.

Section: Site Visit

If your screen risk category is a Moderate or High, you will require a Site Visit before your enrollment can be finalized.  *Note, this will be blank for new enrollments and will not be editable by the provider or TMHP Provider Enrollment.

Click Save.

Repeat as necessary.

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

Instructions on updating the Practice Location Demographics information.

Section: Demographics

Verify the information on file. If you require changes to any of the information below, continue through the next steps:

Updating Practice Location Demographics information

Select the counties you serve in the drop-down menu.

Note: If county restrictions do not exist, you can select "Client Default" rather than add each individual county.

Select answers to Additional Language.

Select the Patient Age Limitations. Enter the age range of clients you are accepting as patents.

Select Patient Gender Limitations at this location.

Provide Office hours for each day of the week: add in the open time and closing time for each day of the week..

Click Save.

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

Section: Managing Employees

Updating a Practice Location Managing Employee information:

Note: If an additional managing employee has been added to your practice location, you must submit a change in Ownership/Controlling Interest update prior to completing this update.

When the change in Ownership/Controlling Interest update has been completed and approved, you may submit a new request to update your managing employee information.

If you require an end date to an existing managing employee, click the ellipses (…) icon and click Remove to delete the existing managing employee. A pop-up warning will appear asking if you are sure you want to continue. If you do, click Ok.

Please complete the following section for addresses that correspond to your situation:

Section: Managing Employees

1.  Click +Add Managing Employee Association. The "Add Employee" modal will appear.

2. Select the managing employee at this location by clicking on the "Selected Employee" drop-down menu.

3.  Select the role of the managing employee by clicking on the "Managing Employee Role" drop-down menu.

4.  Enter the start date at this location.

5. Click Save

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

Section: Mailing/Contact Address

1.Select +Add Mailing/Contact Addresses to add each contact or mailing address associated to your Practice Location.

2. Select the Address Type from the drop-down menu

KHC requires an Address Type of Mailing with a Contact Type of Social Worker.

KHC requires an Address Type of Contact Address with a Contact Type of Enrollment Contact.

3. Enter the Location Name for this address (optional)

4. Enter the address below with the following information:

Street Address 1

Street Address 2: for Suite Number or Apartment Number.

City

State.

Zip Code + 4

Verify the address.

If the address verification shows an error, and the location entered is accurate, select “Continue with address entered.”

Enter the Phone Number & extension

Enter the Fax Number (optional).

5. Contact Information

Select a Contact Type from the drop-down menu.

For KHC Enrollments, you must enter at least one contact type of Social Worker

Enter the first name and last name for the contact at this address.

KHC requires an Contact Type of Social Worker within the Mailing/Contact Address type Mailing Address

KHC requires an Contact Type of Enrollment Contact within the Mailing/Contact Address type Contact Address

6.  Click Save.

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

Instructions for completing the Practice Location Page

Instructions for completing the Billing Practice Location Table

The Practice Location Information table will display all group locations the performing provide is associated with.

Each location will display in the table with the following data.

LOCATION OR GROUP NAME

Group NPI: This is the Group NPI the performing provider’s practice location is prepopulated from.

Group Name: This is the name of the Group the practice location is managed by.

LOCATION

Group Practice Location: The Location displayed is prepopulated from the Group NPI Approved record. If this address needs to be modified the Group NPI maintaining the practice location must submit a PEMS request to modify the information.

TYPE

Location Type: Performing will display for all practice locations managed by a group NPI.

STATUS

Practice Location Status: The practice location status will change dependent on the Programs and Services participation Statuses.

REQUEST ACTION

Practice Location Activity:

The Request Action status will show a “Edited” status when the information in the existing practice location has been modified in the PEMS request.

The Request Action status will show a “Added” for all locations seeking enrollment within the PEMS request.

The location on file is copied from the location selected in the Services Provided page, which is also on file for the group. To enter and edit your practice location record, click on the ellipses (…) and select Open. This will bring up the Practice Location sub-pages.

The location on file is copied from the location on file for the group NPI. To enter and edit your practice location record, click on the ellipses (…) and select Open. This will bring up the Practice Location sub-pages.

Note: All Performing locations the provider is associate with will be editable in a Group Initiated Revalidation request.

If additional information is needed, please reach out to the Individual NPI admin.

Section: Basic Information

The address on the Basic Information page will be pre-populated from the Practice Location on file for the Group. The following fields will be editable.

Location Name – Update the provider’s Location Name.

Phone Number – enter the phone number of the practice location address.

Phone Number Extension – enter the extension (optional)

Fax Number – enter the fax number of the practice location. (optional)

Click Save.

Section: Practice Location Address Record History

This will contain the previous address information that was on the enrollment record for the NPI that has since been end dated as a practice location. This information will be blank for New Enrollments and un-editable.

Location Name

Address

Effective dates

Once you have verified your address information, click “Save”.

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

Section: Programs and Services Participation

The Program and Services Participation page displays the current programs associate with the practice location.

The Program and Services Participation table will be pre-populated with your Primary Taxonomy Code, Program, Benefit Code, Status, Effective Dates, & Request Action. To enter and edit your Programs and Services Participation Details page, click on the ellipses (…) and select Open.

PRIMARY TAXONOMY: Displays the Taxonomy Code used to identify the provider type and specialty for enrollment.

PROGRAM: Displays the Program associated with the practice location.

BENEFIT CODE: The Benefit Code will display if applicable for your program.

STATUS: The following statues display the programs current participation - Enrolled, Deactivated, Disenrolled, Pending Enrollment, Pending Reenrollment, Pending Disenrollment.

EFFECTIVE DATES: The programs participation dates display.

REQUEST ACTION: Program activity displayed.

The Request Action status will show a “Edited” status when the information in the existing program has been modified in the PEMS request.

*The Request Action status will show a “Added” status for all programs seeking enrollment within the PEMS request.

Selecting the +Add Program and Service Participation button will navigate to the Program Participation section to add a program & provider type.

Section: Program Participation

This information will be pre-populated with the Program and Taxonomy code of the Group.

SELECT THE ASSOCIATED GROUP’S PROGRAM: The Group’s program and primary taxonomy code are displayed in this field. The SELECT THE ASSOCIATED GROUP'S PROGRAM field is not editable for existing programs.

Note: The fields following fields are conditionally displayed and based on your program and participation status.

Do You Wish To End Your Participation? Selecting “Yes” will end your participation with this program and provider type for this practice location.

Do You Wish To Resume Your Participation? Selecting “Yes” will reenroll your program and provider type for this practice location.

Retroactive Claim Date: This field will display your program/provider type effective date. For newly added programs this date will be blank.

Section: Status Codes 

The following section will display any current status codes that affect your enrollment record. This information will be blank and uneditable for New Enrollments.

Code: Status code number will display.

Type: The status code Type will display

Description: Status code details will display

Effective Dates: The Status code effective dates will display. Is the status code is currently active there will not be an end date.

Section: Service Provided

Primary Taxonomy - The Taxonomy code will be pre-populated and un-editable.

Provider Type – The Provider Type description will be pre-populated and un-editable.

Provider Specialty – The Provider Specialty description will be pre-populated and un-editable.

Provider Subspecialty – The Provider Subspecialty description will be pre-populated and un-editable.

Benefit Code – The Benefit Code description will be pre-populated and un-editable.

Secondary Taxonomy – The Secondary Taxonomy field is optional. Please only select a Taxonomy not applied to the Primary Taxonomy field.

Section: Add Licenses / Certifications / Accreditations

Click +Association License/Certification/Accreditation. This will pop-up the "Add Licenses/Certifications /Accreditations" modal.

From the drop-down menu, select the License/Certification/Accreditation you wish to associate to this Program/Provider Type.

Click Save.

Note: For new enrollments the “+Association License/Certification/Accreditation” button will not be present until the page is saved and PEMS determines the provider type requires a license to be added.

Section: Demographics

Select the Patient Gender Limitations from the drop-down menu

Select the Patient Age Limitations – Start from the drop-down menu.

Select the Patient Age Limitations – End from the drop-down menu.

Select whether you are accepting Patients from the drop-down menu.

Section Program-Specific Questions

The following section will have program-specific questions for the enrolling provider to complete for each program selected above.

For KHC providers, the Medicare Information in your Acute Care enrollment record will be displayed below in the Alternate Identifiers section after your enrollment is approved.

Are you using a Medicare Certification Number for this location? Click Yes or No.

If you select Yes, you will complete the following:

Select the “Add Medicare Number” button. The following will appear:

Medicare Number

Medicare Effective Date

Medicare End Date

If you select No, the following checkboxes will appear and will be required to be selected:

"I understand that the services that are provided to Medicare-eligible clients cannot be billed to Medicaid unless Medicare is billed first. If the services are not billed to Medicare first, Medicaid may recoup payments for the services. I also understand that I cannot bill the client for these services.”: Check the box to acknowledge this statement.

Medicare Waiver Request: You must select one of the following requests for enrolling without Medicare, if your enrollment type has Medicare as a pre-requisite:

I certify my practice is limited to individuals’ birth through 20 years of age. I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. - Select this if the services you provide are for Pediatric services for individuals age 0 through 20.

I certify that the service(s) I render is /are not recognized by Medicare for reimbursement. I further certify the claims for these services will not be billed to Medicare (this includes Medicare crossover claims). I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. - Select this if the services you provide are for clients of all ages.

In the box below the checkboxes, you will have to provide an explanation to justify your reasons for making a Medicare Waiver Request.

Section: Traditional Medicaid/Acute Care:

Do you offer Telehealth services? – Select Yes or No

Do you offer Telemedicine services? – Select Yes or No

Do you want to be a limited provider? – Select Yes or No.

Do you provide hearing services for children? – Select Yes or No

Note, if you are not providing hearing aid services, you may select No.

Are you an Urgent Care Center? – Select Yes or No

Note, if you are not enrolling into an Urgent Care Center, you may select No

Section: Healthy Texas Women

Healthy Texas Women Select Yes or No for the attestation for providing Healthy Texas Women (HTW) or HTW Plus services at this location.

Section: Pharmacy History

This section is un-editable and only applicable for Vendor Drug Program provider.

Section: Alternate Identifiers

This section is un-editable and displays alternate Ids associated to the Program/Provider Type.

Click Save.

Section:Demographics information

1. Select the counties you serve in the drop-down menu.

Note: If county restrictions do not exist, you can select "Client Default" rather than add each individual county.

2. Select Additional Languages other than English that you communicate to your clients.

3. Provide Office hours for each day of the week: add in the open time and closing time for each day of the week.

4. Select “Yes or No” to Urgent Care Center.

5. Click Save

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

This page is not applicable for Performing Provider enrollments. Please continue to the next page.

Instructions for completing the Practice Location Page

For each new practice location, click Add New Practice Location to add each address at which you ordering, referring, or prescribe services.

Note: Use the left navigation arrow in the blue header to return to the main page navigation. After you click Add +Add Practice Location, an “Add Practice” modal will display and require selection of the type of Location:

Do you bill for services at this location? Select No

Are you a member of a group at this location? Select No

A checkbox with the statement “I understand that in the future if I wish to seek reimbursements for services performed to Medicaid recipients, I must submit a new enrollment application to be eligible for Medicaid billing” will appear after "No" is selected.

Note: This checkbox is for enrollment as an Ordering, Referring, or Prescribing (ORP) provider. If you currently have an existing Medicaid enrollment, by selecting this checkbox, you are voluntarily withdrawing your Medicaid and Children with Special Health Care Needs (CSHCN) Services Program billing provider enrollment to enroll for the sole purpose of ordering/referring. Choose this option only if you will no longer be billing Texas Medicaid .

Select Add Practice button

Section: Basic Information

Note: If the address requires corrections or changes and is greyed out, click the “Click to change address” checkbox to make edits.

Location Name (Optional–This name will appear in the practice locations table for each address associated to your enrollment record for quick reference)

Address Line 1

Address Line 2 (Optional–for Suite Number or Apartment Number)

City

State

For providers that are out-of-state providers:

If your practice location is 50 miles outside from the Texas border, you must submit additional documentation according to Texas Administrative Code TAC § 352.17.

This can be attached below by clicking the “Click here to select files” button.

Zip Code

Zip Code +4 (optional - PEMS will look up this number according to U.S. Postal Service data when you click "Verify Address")

Click Verify Address.

Verify that the address that you entered matches the address where services are rendered to clients. You must not enter the accounting, corporate, or mailing address information as the "Practice Location"; you can provide the information as "Additional Address(es)" associated to each practice location as applicable.

If the address verification shows an error and the practice location entered is accurate, click Continue with address entered.

Phone Number

Extension (Optional–This information will appear in the Online Provider Lookup)

Fax Number (Optional–This information will appear in the Online Provider Lookup)

Effective Date – This will be the effective date of this practice location. This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

End Date – This will be the end date for this practice location. This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

End Reason – The reason for this practice location to be end dated will be entered in this field. This will be blank and uneditable by the Provider and Provider Enrollment for new enrollments.

Section Practice Location Address Record History

This will contain the previous address information that was on the enrollment record for the National Provider Identifier (NPI) that has since been end dated as a practice location. This information will be blank and uneditable for new enrollments.

Location Name

Address

Effective dates.

Once you have verified your address information, click “Save”.

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

Section: Programs and Services Participation

Click the +Add Program and Service Participation button if you don’t see the program you are wanting to enroll into. This will navigate to the Program Participation section.

If you do see the program you are wanting to enroll into, select the ellipsis on the right to enter the segment. This will navigate to the Program Participation section.

The Program and Services Participation information will be pre-populated from your Taxonomy Code, Provider Type and Specialty selected on the Services Provided page. To enter and edit your Programs and Services Participation information, click on the ellipses (…) and select Open.

This information will be pre-populated with the Program and Taxonomy code of the Group.

Verify the information on file. If you require changes to any of the information below, continue through the next steps:

Select the Acute Care Fee-for-Services you will be associating to your practice location using the “Select a Program” drop-down menu.

The following will be greyed out as view-only data:

Start Date—Start date of your enrollment participating in Medicaid at this practice location

End Date—End date of your enrollment participating in Medicaid at this practice location

End Reason—Reason for ending your participation in Medicaid at this practice location

Section: Program Participation

Select the State Health-Care Program Service (or Services) you will be associating to your practice location using the “Select a Program” drop-down menu. You may select more than one option.

Select A Program - Select the State Health-Care Program Service you will be associating to your practice location using the “Select a Program” drop-down menu.

Retroactive Claim Date – This will be blank and uneditable for New Enrollments.

Section: Status Codes 

The following section will display any current status codes that affect your enrollment record. This information will be blank and uneditable for new enrollments.

Type—Type of status code

Description—Description of status code

Effective Dates—Effective date of status code

Section: Service Provided

Provide the following information:

Primary Taxonomy—Select the available taxonomy code from the drop-down menu.

Provider Type—Select the available provider type description from the drop-down menu.

Provider Specialty—Select the available specialty description from the drop-down menu.

Provider Sub-Specialty—Select the available subspecialty description from the drop-down menu.

Secondary Taxonomy—Select a secondary taxonomy not yet applied to the primary taxonomy code above (optional).

Section: Add Licenses / Certifications / Accreditations

Click +Association License/Certification/Accreditation. This will pop-up the "Add Licenses/Certifications /Accreditations" modal.

Click the "License/Certification/Accreditation" from the drop-down menu. 

This list is prepopulated from the licenses, certifications, or accreditations entered earlier in the application.

If you do not see your license represented in this drop-down menu, you must go back to the "Licenses/Certification/Accreditation" page to add it

Demographics

PATIENT GENDER LIMITATIONS - select the patient gender Limitation

PATIENT AGE LIMITATIONS - START-select the patient age Start date

PATIENT AGE LIMITATIONS - END-select the patient age End date

ACCEPTING PATIENTS-make a selection from the drop down options.

Section Reassignment of Benefits History

*This section will be blank for Ordering- or Referring-Only providers.

Section Program-Specific Questions

Training Provided – Select No

Do you offer Telehealth services? – Select No

Do you offer Telemedicine services? – Select No

Do you want to be a limited provider? – Select No

Do you provide hearing services for children? – Select No

Are you an Urgent Care Center? – Select No

Click Save.

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