Instructions for Completing the Provider Information page
Instructions for Reviewing the Provider Information page
Maintenance—Provider Information
Select the Application Type from the left navigation menu.
Enter the following information for the enrolling.
Name (as shown on your income tax return) - Enter the “Organization Name” as stated on your income tax return.
If the facility is licensed or certified, the name that you enter must match the name on your professional license.
Note: If the facility is also Medicare enrolled, the name entered must also match the name on your Medicare information.
Doing Business As—Enter your "doing business as" name.
Primary Email Address—Enter a primary email address.
Secondary Email Address—Enter a secondary email address.
Enter the following provider’s name information.
First Name
Middle Name (if applicable)
Last Name
Suffix (if applicable)
If the provider is licensed or certified, the first and last name that you enter must match the name on your professional license.
Social Security Number—Enter the provider’s Social Security Number.
Date of Birth—Enter the provider’s Date of Birth.
Gender—Select the provider’s gender from the drop-down menu.
ID Type—Select an identification option for the provider from the drop-down menu.
ID Number—Enter the provider’s identification number.
State Issuer—Select the provider’s identification state issuer from the drop-down menu.
Issue Date—Enter the date the provider’s identification type was issued.
Expiration Date—Enter the date the provider’s identification type expires.
Primary Email Address—Enter a primary email address for the provider.
Secondary Email Address—Enter a secondary email address.
Maiden Name, Other Alias, Nicknames
If the enrolling provider has a Maiden Name, Other Alias or Nickname:
Click +Add Maiden Name, Other Alias, Nicknames. A new sub-page will open.
Select the “Name” Type using the drop-down menu.
Enter the “First Name”
Enter the “Middle Name” (if applicable)
Enter the “Last Name”
Enter the “Suffix”
Review the information below to ensure it is still accurate; if any changes are needed, update the fields accordingly.
Instructions for Updating the Provider Information Name & DBA Name.
Review the information below to ensure it is still accurate. If any changes are needed, update the field accordingly.
Name (as shown on your income tax return)—Update the organization name as stated on the income tax return.
If the facility is licensed or certified, the name that you enter must match the name on your professional license.
Doing Business As—Update your "doing business as" name.
Primary Email Address (Un-editable. To make edits to this field, you must select the appropriate maintenance type [Maintenance – Provider Information – Change Email])
Secondary Email Address (Un-editable. To make edits to this field, you must select the appropriate maintenance type [Maintenance – Provider Information – Change Email])
Update the provider’s name information (as shown on the provider's income tax return):
First Name
Middle Name (if applicable)
Last Name
Suffix (if applicable)
If the provider is licensed or certified, the first and last name that you enter must match the name on your professional license.
Update the provider’s Social Security Number.
Update the provider’s Date of Birth.
Select the provider’s Gender from the available drop-down menu.
Select the provider’s ID Type from the available drop-down menu.
Update the provider’s ID Number.
Select the provider’s ID State Issuer from the available drop-down menu.
Update the provider’s Issue Date for their ID.
Update the provider’s Expiration Date for their ID.
The Primary Email Address field is un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Change Email).
The Secondary Email Address field un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Change Email).
Maiden Name, Other Alias, Nicknames
If the enrolling provider has a maiden name, other alias or nickname:
Update the First Name field.
Update the Middle Name field (if applicable).
Update the Last Name field.
Update the Suffix field.
Maintenance—Provider Information–Email Address
Instructions for Updating the Provider Information Email Address.
Review the information below to ensure it is still accurate. If any changes are needed, update the field accordingly.
Name (as shown on your income tax return)—This field is un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Name Update).
Doing Business As—This field is un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Name Update).
Primary Email Address—Update the provider's primary email address.
Secondary Email Address—Update the provider's secondary email address.
Click Verify Email.
Update the Name (as shown on your income tax return) field. This field is un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Name Update).
Social Security Number—This field is un-editable.
Date of Birth—This field is un-editable.
Gender—This field is un-editable.
ID Type—This field is un-editable.
ID Number—This field is un-editable.
State Issuer—This field is un-editable.
Issue Date—This field is un-editable.
Expiration Date—This field is un-editable.
Primary Email address—Update the provider's primary email address.
Secondary Email Address—Update the provider's secondary email address.
Click Verify Email.
Maiden Name, Other Alias, Nickname
Maiden Name, Other Alias, Nicknames—This is is un-editable.
Enrollment Information
This section will house the current status of your enrollment record. Note This information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment Department.
Name (as shown on your income tax return)—Confirm or update the organization name as stated on your income tax return.
If the facility is licensed or certified, the name that you enter must match the name on your professional license.
Doing Business As—Confirm or update your "doing business as" name.
Primary Email Address—Confirm or update the primary email address.
Secondary Email Address—Confirm or update the secondary email address. (Optional)
Maiden Name, Other Alias, Nicknames
If the enrolling provider has a maiden name, other alias or nickname:
Update the “First Name”
Update the “Middle Name” (if applicable)
Update the “Last Name”
Update the “Suffix”
Enrollment Information
This section will house the current status of your enrollment record. Note: this information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment department.
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information will be blank and un-editable for New Enrollments.
Enrollment Status:
Pending–The initial new enrollment application has been received but has not been approved.
Disenrolled – Provider is currently not enrolled with the Medicaid system, is unable to provide services, submit claims for reimbursement, and will need to submit a Reenrollment application. (Not eligible for a Revalidation Enrollment)
Enrolled–The provider is currently enrolled, and is able to provide services and submit claims for reimbursement.
Revalidation Due Date:
The "Revalidation Due Date" will be the date that the enrollment record will need to go through a revalidation per the Affordable Care Act (ACA) guidelines.
Screen Risk Category:
The Centers for Medicare & Medicaid Services (CMS) has defined three levels of risk: limited, moderate, and high. The categories are assigned to each provider type based on an assessment of the risk of fraud, waste, and abuse. The Texas Health and Human Services Commission (HHSC) has the authority to assign a risk level higher than that assigned by Medicare. HHSC assesses risk using criteria similar to that used by CMS, which includes trends of fraud, waste, and abuse specific to Texas provider types.
Screen Risk Category Reason Code
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information will be blank and un-editable for New Enrollments.
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information cannot be edited by the provider or Provider Enrollment and is in a View-Only status.
Screen Risk Category Reason Code—According to the Code of Federal Regulations (CFR) 455.450€, certain provider types must be elevated to a "high risk" category. The "Screen Risk Category Reason Code" field will display applicable reason codes associated to your National Provider Identifier (NPI).
Date—This field will display the date the "Screen Risk Category Reason Code" was applied to your enrollment record.
Description—This field will display the reason code description, which should either be a category of "Standard Risk Level" or the elevation reasons.
Enrollment Periods
This section will house the Enrollment Periods for your Enrollment Record. Please Note, this information will be blank and un-editable for New Enrollments.
This section will house the enrollment periods for your enrollment Record. Note: This information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment Department.
Begin Date—This field displays the date that the enrollment record was created and is program-dependent.
End Date—This field displays the date that the enrollment record was ended, and is considered to be the "Revalidation Due Date" or a time-limited enrollment date imposed by the state of Texas.
A provider must submit a revalidation application and comply with Title 1 Texas Administrative Code (TAC), Part 15, Chapters 352 and 371 (relating to Applying for Enrollment) at least every five years. The time frame for reenrollment is based on the provider's screening level unless the Texas Health and Human Services Commission (HHSC) determines a shorter enrollment period.
Most providers have an enrollment period of five years. Some providers have shorter enrollment periods, which are based on risk categories and other considerations.
Revalidation Due Date
To remain in compliance with Title 42 Code of Federal Regulations §455.414, providers must complete the revalidation process before the end of their enrollment period, which is also called the “revalidation due date.”
If a provider’s enrollment period ends before TMHP has received the provider’s revalidation application, TMHP automatically disenrolls providers on the date that their enrollment period ends. The provider must then submit a reenrollment 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 reenrollment process.
Click Save.
Access the left navigation and select the next available page to continue entering your application.
When you are ready to submit, click Submit All Changes.
When you are ready to submit, click Submit All Changes.
Instructions for Completing the Provider Information page
Instructions for Reviewing the Provider Information page
Instructions for Reviewing the Provider Information page
Instructions for Reviewing the Provider Information page
Maintenance—Provider Information
Enter the following information for the enrolling.
Enter the following provider’s name information (as shown on the provider's income tax return):
First Name
Middle Name (if applicable)
Last Name
Suffix (if applicable)
If the provider is licensed or certified, the first and last name that you enter must match the name on your professional license or with Medicare.
Social Security Number—Enter the provider’s Social Security Number.
Date of Birth—Enter the provider’s Date of Birth.
The provider’s “Gender” will be pre-populated.
ID Type—Select an identification option for the provider from the drop-down menu.
ID Number—Enter the provider’s identification number.
State Issuer—Select the provider’s identification state issuer from the drop-down menu.
The provider’s “Issue Date” for their ID will be pre-populated.
Expiration Date—Enter the date the provider’s identification type expires.
Maiden Name, Other Alias, Nicknames
If the enrolling provider has a Maiden Name, Other Alias or Nickname:
Click +Add Maiden Name, Other Alias, Nicknames. A new sub-page will open.
Select the “Name” Type using the drop-down menu.
Enter the “First Name”
Enter the “Middle Name” (if applicable)
Enter the “Last Name”
Enter the “Suffix”
Note: if the provider’s name on file with the License Board is different from what is on file with Medicare, you may enter the Alias with the alternate name.
Click Save
Review the information below to ensure it is still accurate; if any changes are needed, update the fields accordingly.
Review the information below to ensure it is still accurate; if any changes are needed, update the fields accordingly.
Review the information below to ensure it is still accurate; if any changes are needed, update the fields accordingly.
Instructions for Updating the Provider Information Name & DBA Name
Review the information below to ensure it is still accurate. If any changes are needed, update the field accordingly.
Name (as shown on your income tax return)—Update the organization name as stated on the income tax return.
If the facility is licensed or certified, the name that you enter must match the name on your professional license.
Doing Business As—Update your "doing business as" name.
Primary Email Address (Un-editable. To make edits to this field, you must select the appropriate maintenance type. [Maintenance – Provider Information – Change Email])
Secondary Email Address (Un-editable. To make edits to this field, you must select the appropriate maintenance type [Maintenance – Provider Information – Change Email])
Update the provider’s name information (as shown on the provider's income tax return):
First Name
Middle Name (if applicable)
Last Name
Suffix (if applicable)
If the provider is licensed or certified, the first and last name that you enter must match the name on your professional license.
Update the provider’s Social Security Number.
Update the provider’s Date of Birth.
Select the provider’s Gender from the available drop-down menu.
Select the provider’s ID Type from the available drop-down menu.
Update the provider’s ID Number.
Select the provider’s ID State Issuer from the available drop-down menu.
Update the provider’s Issue Date for their ID.
Update the provider’s Expiration Date for their ID.
The Primary Email Address field is un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Change Email).
The Secondary Email Address field un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Change Email).
Maiden Name, Other Alias, Nicknames
If the enrolling provider has a maiden name, other alias or nickname:
Update the First Name field.
Update the Middle Name field (if applicable).
Update the Last Name field.
Update the Suffix field.
Note: if the provider’s name on file with the License Board is different from what is on file with Medicare, you may enter the Alias with the alternate name.
2. Click Save.
This will take you back to the main Basic Information page.
Maintenance—Provider Information–Email Address
Instructions for Updating the Provider Information Email Address.
Review the information below to ensure it is still accurate. If any changes are needed, update the field accordingly.
Name (as shown on your income tax return)—This field is un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Name Update).
Doing Business As—This field is un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Name Update).
Primary Email Address—Update the provider's primary email address.
Secondary Email Address—Update the provider's secondary email address.
Click Verify Email.
Update the Name (as shown on your income tax return) field. This field is un-editable. To make edits to this field, you must select the appropriate maintenance type (Maintenance – Provider Information – Name Update).
Social Security Number—This field is un-editable.
Date of Birth—This field is un-editable.
Gender—This field is un-editable.
ID Type—This field is un-editable.
ID Number—This field is un-editable.
State Issuer—This field is un-editable.
Issue Date—This field is un-editable.
Expiration Date—This field is un-editable.
Primary Email address—Update the provider's primary email address.
Secondary Email Address—Update the provider's secondary email address.
Click Verify Email.
Maiden Name, Other Alias, Nickname
Maiden Name, Other Alias, Nicknames—This is is un-editable.
Enrollment Information
This section will house the current status of your enrollment record. Note This information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment Department.
Verify or update the provider’s name information (as shown on the provider's income tax return):
If the facility is licensed or certified, the name that you enter must match the name on your professional license.
First Name
Middle Name (if applicable)
Last Name
Suffix (if applicable)
If the provider is licensed or certified, the first and last name that you enter must match the name on your professional license or with Medicare.
The provider’s “Social Security Number” will be masked but the field is editable.
The provider’s “Date of Birth” will be masked but the field will be editable.
The provider’s “Gender” will be pre-populated.
ID Select the provider’s ID Type from the available drop-down menu.
Update the provider’s ID Number.
Select the provider’s ID State Issuer from the available drop-down menu.
Update the provider’s Issue Date for their ID.
Update the provider’s Expiration Date for their ID.
Maiden Name, Other Alias, Nicknames
If the enrolling provider has a maiden name, other alias or nickname:
Update the “First Name field.”
Update the “Middle Name” field(if applicable).
Update the “Last Name field.”
Update the “Suffix field.”
Note: if the provider’s name on file with the License Board is different from what is on file with Medicare, you may enter the Alias with the alternate name. Do not enter the same First/Last name already list on the Provider Information Basic Information page.
Click Save.
This will take you back to the main Basic Information
Enrollment Information
This section will house the current status of your enrollment record. Note: This information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment department.
Verify or update the provider’s name information (as shown on the provider's income tax return):
If the facility is licensed or certified, the name that you enter must match the name on your professional license.
First Name
Middle Name (if applicable)
Last Name
Suffix (if applicable)
If the provider is licensed or certified, the first and last name that you enter must match the name on your professional license or with Medicare.
The provider’s “Social Security Number” will be masked.
The provider’s “Date of Birth” will be hidden.
The provider’s “Gender” will be pre-populated.
ID Select the provider’s ID Type from the available drop-down menu.
Update the provider’s ID Number.
Select the provider’s ID State Issuer from the available drop-down menu.
Update the provider’s Issue Date for their ID.
Update the provider’s Expiration Date for their ID.
Maiden Name, Other Alias, Nicknames
If the enrolling provider has a maiden name, other alias or nickname:
Update the “First Name”
Update the “Middle Name” (if applicable)
Update the “Last Name”
Update the “Suffix”
Note: if the provider’s name on file with the License Board is different from what is on file with Medicare, you may enter the Alias with the alternate name.
Click Save.
This will take you back to the main Basic Information.
Enrollment Information
This section will house the current status of your enrollment record. Note: his information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment department.
Verify or update the provider’s name information (as shown on the provider's income tax return):
If the facility is licensed or certified, the name that you enter must match the name on your professional license.
First Name
Middle Name (if applicable)
Last Name
Suffix (if applicable)
If the provider is licensed or certified, the first and last name that you enter must match the name on your professional license or with Medicare.
The provider’s “Social Security Number” will be masked.
The provider’s “Date of Birth” will be hidden.
The provider’s “Gender” will be pre-populated.
ID Select the provider’s ID Type from the available drop-down menu.
Update the provider’s ID Number.
Select the provider’s ID State Issuer from the available drop-down menu.
Update the provider’s Issue Date for their ID.
Update the provider’s Expiration Date for their ID.
Maiden Name, Other Alias, Nicknames
If the enrolling provider has a maiden name, other alias or nickname:
Update the “First Name field”
Update the “Middle Name” field (if applicable)
Update the “Last Name field”
Update the “Suffix field”
Note: if the provider’s name on file with the License Board is different from what is on file with Medicare, you may enter the Alias with the alternate name.
Click Save.
This will take you back to the main Basic Information.
Enrollment Information
This section will house the current status of your enrollment record. Note: his information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment department.
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information will be blank and un-editable for New Enrollments.
Enrollment Status:
Enrollment Status:
Enrollment Status:
Enrollment Status:
Pending–The initial new enrollment application has been received but has not been approved.
Disenrolled – Provider is currently not enrolled with the Medicaid system, is unable to provide services, submit claims for reimbursement, and will need to submit a Reenrollment application. (Not eligible for a Revalidation Enrollment)
Enrolled–The provider is currently enrolled, and is able to provide services and submit claims for reimbursement.
Enrolled–The provider is currently enrolled, and is able to provide services and submit claims for reimbursement.
Enrolled–The provider is currently enrolled, and is able to provide services and submit claims for reimbursement.
Revalidation Due Date:
The "Revalidation Due Date" will be the date that the enrollment record will need to go through a revalidation per the Affordable Care Act (ACA) guidelines.
Screen Risk Category:
The Centers for Medicare & Medicaid Services (CMS) has defined three levels of risk: limited, moderate, and high. The categories are assigned to each provider type based on an assessment of the risk of fraud, waste, and abuse. The Texas Health and Human Services Commission (HHSC) has the authority to assign a risk level higher than that assigned by Medicare. HHSC assesses risk using criteria similar to that used by CMS, which includes trends of fraud, waste, and abuse specific to Texas provider types.
Screen Risk Category Reason Code
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information will be blank and un-editable for New Enrollments.
Screen Risk Category Reason Code—According to the Code of Federal Regulations (CFR) 455.450€, certain provider types must be elevated to a "high risk" category. The "Screen Risk Category Reason Code" field will display applicable reason codes associated to your National Provider Identifier (NPI).
Date—This field will display the date the "Screen Risk Category Reason Code" was applied to your enrollment record.
Description—This field will display the reason code description, which should either be a category of "Standard Risk Level" or the elevation reasons.
Enrollment Periods
This section will house the Enrollment Periods for your Enrollment Record. Please Note, this information will be blank and un-editable for New Enrollments.
Begin Date—This field displays the date that the enrollment record was created and is program-dependent.
End Date—This field displays the date that the enrollment record was ended, and is considered to be the "Revalidation Due Date" or a time-limited enrollment date imposed by the state of Texas.
A provider must submit a revalidation application and comply with Title 1 Texas Administrative Code (TAC), Part 15, Chapters 352 and 371 (relating to Applying for Enrollment) at least every five years. The time frame for reenrollment is based on the provider's screening level unless the Texas Health and Human Services Commission (HHSC) determines a shorter enrollment period.
Most providers have an enrollment period of five years. Some providers have shorter enrollment periods, which are based on risk categories and other considerations.
Revalidation Due Date
To remain in compliance with Title 42 Code of Federal Regulations §455.414, providers must complete the revalidation process before the end of their enrollment period, which is also called the “revalidation due date.”
If a provider’s enrollment period ends before TMHP has received the provider’s revalidation application, TMHP automatically disenrolls providers on the date that their enrollment period ends. The provider must then submit a reenrollment 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 reenrollment process.
Click Save.
Access the left navigation and select the next available page to continue entering your application.
Revalidation Due Date:
The "Revalidation Due Date" will be the date that the enrollment record will need to go through a revalidation per the Affordable Care Act (ACA) guidelines. You must complete this revalidation request by the revalidation due date. PEMS will reject this request if you try to submit it after the revalidation due date.
To remain in compliance with Title 42 Code of Federal Regulations §455.414, providers must complete the revalidation process before the end of their enrollment period, which is also called the “revalidation due date.”
If a provider’s enrollment period ends before TMHP has received the provider’s revalidation application, TMHP automatically disenrolls providers on the date that their enrollment period ends. The provider must then submit a reenrollment 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 reenrollment process.
Screen Risk Category:
The Centers for Medicare & Medicaid Services (CMS) has defined three levels of risk: limited, moderate, and high. The categories are assigned to each provider type based on an assessment of the risk of fraud, waste, and abuse. The Texas Health and Human Services Commission (HHSC) has the authority to assign a risk level higher than that assigned by Medicare. HHSC assesses risk using criteria similar to that used by CMS, which includes trends of fraud, waste, and abuse specific to Texas provider types.
Screen Risk Category Reason Code
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information cannot be edited by the provider or Provider Enrollment and is in a View-Only status.
Screen Risk Category Reason Code—According to the Code of Federal Regulations (CFR) 455.450€, certain provider types must be elevated to a "high risk" category. The "Screen Risk Category Reason Code" field will display applicable reason codes associated to your National Provider Identifier (NPI).
Date—This field will display the date the "Screen Risk Category Reason Code" was applied to your enrollment record.
Description—This field will display the reason code description, which should either be a category of "Standard Risk Level" or the elevation reasons.
Enrollment Periods
This section will house the enrollment periods for your enrollment Record. Note: This information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment Department.
Begin Date—This field displays the date that the enrollment record was created and is program-dependent.
End Date—This field displays the date that the enrollment record was ended, and is considered to be the "Revalidation Due Date" or a time-limited enrollment date imposed by the state of Texas.
A provider must submit a revalidation application and comply with Title 1 Texas Administrative Code (TAC), Part 15, Chapters 352 and 371 (relating to Applying for Enrollment) at least every five years. The time frame for revalidation is based on the provider's screening level unless the Texas Health and Human Services Commission (HHSC) determines a shorter enrollment period.
Most providers have an enrollment period of five years. Some providers have shorter enrollment periods, which are based on risk categories and other considerations.
Revalidation Due Date.
Click Save.
Access the left navigation and select the next available page to continue entering your application.
Revalidation Due Date:
The "Revalidation Due Date" will be the date that the enrollment record will need to go through a revalidation per the Affordable Care Act (ACA) guidelines.
Screen Risk Category:
The Centers for Medicare & Medicaid Services (CMS) has defined three levels of risk: limited, moderate, and high. The categories are assigned to each provider type based on an assessment of the risk of fraud, waste, and abuse. The Texas Health and Human Services Commission (HHSC) has the authority to assign a risk level higher than that assigned by Medicare. HHSC assesses risk using criteria similar to that used by CMS, which includes trends of fraud, waste, and abuse specific to Texas provider types.
Screen Risk Category Reason Code
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information cannot be edited by the provider or Provider Enrollment and is in a View-Only status.
Screen Risk Category Reason Code—According to the Code of Federal Regulations (CFR) 455.450€, certain provider types must be elevated to a " high risk" category. The "Screen Risk Category Reason Code" field will display applicable reason codes associated to your National Provider Identifier (NPI).
Date—This field will display the date the "Screen Risk Category Reason Code" was applied to your enrollment record.
Description—This field will display the reason code description, which should either be a category of "Standard Risk Level" or the elevation reasons.
Enrollment Periods
This section will house the enrollment periods for your enrollment Record. Note: This information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment Department.
Begin Date—This field displays the date that the enrollment record was created and is program-dependent.
End Date—This field displays the date that the enrollment record was ended, and is considered to be the "Revalidation Due Date" or a time-limited enrollment date imposed by the state of Texas.
A provider must submit a revalidation application and comply with Title 1 Texas Administrative Code (TAC), Part 15, Chapters 352 and 371 (relating to Applying for Enrollment) at least every five years. The time frame for reenrollment is based on the provider's screening level unless the Texas Health and Human Services Commission (HHSC) determines a shorter enrollment period.
Most providers have an enrollment period of five years. Some providers have shorter enrollment periods, which are based on risk categories and other considerations.
Revalidation Due Date.
To remain in compliance with Title 42 Code of Federal Regulations §455.414, providers must complete the revalidation process before the end of their enrollment period, which is also called the “revalidation due date.”
If a provider’s enrollment period ends before TMHP has received the provider’s revalidation application, TMHP automatically disenrolls providers on the date that their enrollment period ends. The provider must then submit a reenrollment 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 reenrollment process.
Click Save.
Access the left navigation and select the next available page to continue entering your application.
Revalidation Due Date:
The "Revalidation Due Date" will be the date that the enrollment record will need to go through a revalidation per the Affordable Care Act (ACA) guidelines.
Screen Risk Category:
The Centers for Medicare & Medicaid Services (CMS) has defined three levels of risk: limited, moderate, and high. The categories are assigned to each provider type based on an assessment of the risk of fraud, waste, and abuse. The Texas Health and Human Services Commission (HHSC) has the authority to assign a risk level higher than that assigned by Medicare. HHSC assesses risk using criteria similar to that used by CMS, which includes trends of fraud, waste, and abuse specific to Texas provider types.
Screen Risk Category Reason Code
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information cannot be edited by the provider or Provider Enrollment and is in a View-Only status.
Screen Risk Category Reason Code—According to the Code of Federal Regulations (CFR) 455.450€, certain provider types must be elevated to a "high risk" category. The "Screen Risk Category Reason Code" field will display applicable reason codes associated to your National Provider Identifier (NPI).
Date—This field will display the date the "Screen Risk Category Reason Code" was applied to your enrollment record.
Description—This field will display the reason code description, which should either be a category of "Standard Risk Level" or the elevation reasons.
Enrollment Periods
This section will house the enrollment periods for your enrollment Record. Note: This information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment Department.
Begin Date—This field displays the date that the enrollment record was created and is program-dependent.
End Date—This field displays the date that the enrollment record was ended, and is considered to be the "Revalidation Due Date" or a time-limited enrollment date imposed by the state of Texas.
A provider must submit a revalidation application and comply with Title 1 Texas Administrative Code (TAC), Part 15, Chapters 352 and 371 (relating to Applying for Enrollment) at least every five years. The time frame for reenrollment is based on the provider's screening level unless the Texas Health and Human Services Commission (HHSC) determines a shorter enrollment period.
Most providers have an enrollment period of five years. Some providers have shorter enrollment periods, which are based on risk categories and other considerations.
Revalidation Due Date.
To remain in compliance with Title 42 Code of Federal Regulations §455.414, providers must complete the revalidation process before the end of their enrollment period, which is also called the “revalidation due date.”
If a provider’s enrollment period ends before TMHP has received the provider’s revalidation application, TMHP automatically disenrolls providers on the date that their enrollment period ends. The provider must then submit a reenrollment 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 reenrollment process.
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Revalidation Due Date:
The "Revalidation Due Date" will be the date that the enrollment record will need to go through a revalidation per the Affordable Care Act (ACA) guidelines.
Screen Risk Category:
The Centers for Medicare & Medicaid Services (CMS) has defined three levels of risk: limited, moderate, and high. The categories are assigned to each provider type based on an assessment of the risk of fraud, waste, and abuse. The Texas Health and Human Services Commission (HHSC) has the authority to assign a risk level higher than that assigned by Medicare. HHSC assesses risk using criteria similar to that used by CMS, which includes trends of fraud, waste, and abuse specific to Texas provider types.
Screen Risk Category Reason Code
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information will be blank and un-editable for New Enrollments.
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information cannot be edited by the provider or Provider Enrollment and is in a View-Only status.
Screen Risk Category Reason Code—According to the Code of Federal Regulations (CFR) 455.450€, certain provider types must be elevated to a "high risk" category. The "Screen Risk Category Reason Code" field will display applicable reason codes associated to your National Provider Identifier (NPI).
Date—This field will display the date the "Screen Risk Category Reason Code" was applied to your enrollment record.
Description—This field will display the reason code description, which should either be a category of "Standard Risk Level" or the elevation reasons.
Enrollment Periods
This section will house the enrollment periods for your enrollment Record. Note: This information is in view-only status and cannot be edited by the provider nor the TMHP Provider Enrollment Department.
Begin Date—This field displays the date that the enrollment record was created and is program-dependent.
End Date—This field displays the date that the enrollment record was ended, and is considered to be the "Revalidation Due Date" or a time-limited enrollment date imposed by the state of Texas.
A provider must submit a revalidation application and comply with Title 1 Texas Administrative Code (TAC), Part 15, Chapters 352 and 371 (relating to Applying for Enrollment) at least every five years. The time frame for reenrollment is based on the provider's screening level unless the Texas Health and Human Services Commission (HHSC) determines a shorter enrollment period.
Most providers have an enrollment period of five years. Some providers have shorter enrollment periods, which are based on risk categories and other considerations.
Revalidation Due Date.
To remain in compliance with Title 42 Code of Federal Regulations §455.414, providers must complete the revalidation process before the end of their enrollment period, which is also called the “revalidation due date.”
If a provider’s enrollment period ends before TMHP has received the provider’s revalidation application, TMHP automatically disenrolls providers on the date that their enrollment period ends. The provider must then submit a reenrollment 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 reenrollment process.
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When you are ready to submit, click Submit All Changes.
Instructions for Completing the Provider Information page
Enter the following information for the enrolling.
Enter the following provider’s name information.
First Name
Middle Name (if applicable)
Last Name
Suffix (if applicable)
If the provider is licensed or certified, the first and last name that you enter must match the name on your professional license.
Social Security Number—Enter the provider’s Social Security Number.
Date of Birth—Enter the provider’s Date of Birth.
Gender—Select the provider’s gender from the drop-down menu.
ID Type—Select an identification option for the provider from the drop-down menu.
ID Number—Enter the provider’s identification number.
State Issuer—Select the provider’s identification state issuer from the drop-down menu.
Issue Date—Enter the date the provider’s identification type was issued.
Expiration Date—Enter the date the provider’s identification type expires.
Primary Email Address—Enter a primary email address for the provider.
Secondary Email Address—Enter a secondary email address.
Maiden Name, Other Alias, Nicknames
If the enrolling provider has a Maiden Name, Other Alias or Nickname:
Click +Add Maiden Name, Other Alias, Nicknames. A new sub-page will open.
Select the “Name” Type using the drop-down menu.
Enter the “First Name”
Enter the “Middle Name” (if applicable)
Enter the “Last Name”
Enter the “Suffix”
Social Security Number—This field is un-editable
Enrollment Information
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information will be blank and un-editable for New Enrollments.
Enrollment Status:
Pending–The initial new enrollment application has been received but has not been approved.
Revalidation Due Date:
The "Revalidation Due Date" will be the date that the enrollment record will need to go through a revalidation per the Affordable Care Act (ACA) guidelines.
Screen Risk Category:
The Centers for Medicare & Medicaid Services (CMS) has defined three levels of risk: limited, moderate, and high. The categories are assigned to each provider type based on an assessment of the risk of fraud, waste, and abuse. The Texas Health and Human Services Commission (HHSC) has the authority to assign a risk level higher than that assigned by Medicare. HHSC assesses risk using criteria similar to that used by CMS, which includes trends of fraud, waste, and abuse specific to Texas provider types.
Screen Risk Category Reason Code
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information will be blank and un-editable for New Enrollments.
This section will house the Screen Risk Category Reason code for the elevation of the provider’s Screen Risk Category. Please Note, this information cannot be edited by the provider or Provider Enrollment and is in a View-Only status.
Screen Risk Category Reason Code—According to the Code of Federal Regulations (CFR) 455.450€, certain provider types must be elevated to a "high risk" category. The "Screen Risk Category Reason Code" field will display applicable reason codes associated to your National Provider Identifier (NPI).
Date—This field will display the date the "Screen Risk Category Reason Code" was applied to your enrollment record.
Description—This field will display the reason code description, which should either be a category of "Standard Risk Level" or the elevation reasons.
Enrollment Periods
This section will house the Enrollment Periods for your Enrollment Record. Please Note, this information will be blank and un-editable for New Enrollments.
Begin Date—This field displays the date that the enrollment record was created and is program-dependent.
End Date—This field displays the date that the enrollment record was ended, and is considered to be the "Revalidation Due Date" or a time-limited enrollment date imposed by the state of Texas.
A provider must submit a revalidation application and comply with Title 1 Texas Administrative Code (TAC), Part 15, Chapters 352 and 371 (relating to Applying for Enrollment) at least every five years. The time frame for reenrollment is based on the provider's screening level unless the Texas Health and Human Services Commission (HHSC) determines a shorter enrollment period.
Most providers have an enrollment period of five years. Some providers have shorter enrollment periods, which are based on risk categories and other considerations.
Revalidation Due Date
To remain in compliance with Title 42 Code of Federal Regulations §455.414, providers must complete the revalidation process before the end of their enrollment period, which is also called the “revalidation due date.”
If a provider’s enrollment period ends before TMHP has received the provider’s revalidation application, TMHP automatically disenrolls providers on the date that their enrollment period ends. The provider must then submit a reenrollment 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 reenrollment process.
Click Save.
Access the left navigation and select the next available page to continue entering your application.