Exhibit D, Texas Medicaid Provider Procedures Manual.pdf

RFP No. HHS0017108 Exhibit D October 2025

Texas Medicaid Provider Procedures Manual

The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health and Human Services Commission.

Volumes 1 & 2

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 OCTOBER 2025

PRELIMINARY INFORMATION

RFP No. HHS0017108 Exhibit D Table of Contents

Welcome—Texas Medicaid Provider Procedures Manual

Copyright Acknowledgments

Contents

Volume 1—General Information

Volume 2—Provider Handbooks

Introduction

Texas Medicaid Administration

CPT ONLY - COPYRIGHT 2024 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

PRELIMINARY INFORMATION OCTOBER 2025

Welcome—Texas Medicaid Provider Procedures Manual

This manual is a comprehensive guide for Texas Medicaid providers. It contains information about Texas Medicaid fee-for-service benefits, policies, and procedures including medical, dental, and children’s services benefits.

Refer to: The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks) for information about the Medicaid Managed Care, which is administered by Texas Health and Human Services Commission (HHSC)-contracted managed care organizations (MCOs), dental managed care organizations, and behavioral health organizations (BHOs) across the state.

The Texas Medicaid Provider Procedures Manual is updated monthly on the TMHP website at www.tmhp.com to include revisions to policies and procedures that went into effect in the prior month.

The manual is available in portable document format (PDF) as a complete book and as individual sections and handbooks. A hypertext markup language (HTML) version is also be available.

The current version of the manual always appears prominently on the Texas Medicaid Provider Proce-dures Manual web page. All previously published annual editions of the Texas Medicaid Provider Procedures Manual have been archived. Users can access the archives through links on the Texas Medicaid Provider Procedures Manual web page.

Providers can determine what has changed each month by following the Release Notes link on the Texas Medicaid Provider Procedures Manual web page. The release notes include the sections and handbooks that have changed for the current month and the nature of the changes. Most changes have been previ-ously announced in news articles on the TMHP website, and, where appropriate, the release notes link to prior website articles.

Publishing the manual monthly has eliminated the need for the Texas Medicaid Bulletin, which was discontinued following the publication of the September/October 2012 Texas Medicaid Bulletin, No.

243. Special bulletins, such as the annual Healthcare Common Procedure Coding System (HCPCS) bulletin, which is published in January of each year, will continue to be published on an as-needed basis.

The Texas Medicaid Provider Procedures Manual is divided into two volumes as follows:

• Volume 1: General Information

Volume 1 applies to all health-care providers who are enrolled in Texas Medicaid and provide services to Texas Medicaid fee-for-service clients. The sections in Volume 1 include general infor-mation for enrolling in the program, receiving appropriate reimbursement, prior authorizations, claim submissions and appeals for services rendered.

• Volume 2: Provider Handbooks

Each handbook in Volume 2 covers Medicaid policies, procedures, and claims filing requirements for specific products or services. Volume 2 includes the following handbooks:

• Ambulance Services Handbook

• Behavioral Health, Rehabilitation, and Case Management Services Handbook

• Certified Respiratory Care Practitioners (CRCP) Services Handbook

• Children’s Services Handbook

• Clinics and Other Outpatient Facility Services Handbook

• Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook

• Gynecological, Obstetrics, and Family Planning Title XIX Services

• Health and Human Services Commission Family Planning Program Services Handbook

• Healthy Texas Women Program Handbook

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• Home Health Nursing and Private Duty Nursing Services Handbook

• Inpatient and Outpatient Hospital Services Handbook

• Medicaid Managed Care Handbook

• Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook

• Medical Transportation Program Handbook

• Outpatient Drug Services Handbook

• Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook

• Radiology and Laboratory Services Handbook

• School Health and Related Services Handbook

• Telecommunications Services Handbook

• Vision and Hearing Services Handbook

Copyright Acknowledgments Use of the AMA’s copyrighted CPT® is allowed in this publication with the following disclosure:

“Current Procedural Terminology (CPT) is copyright © 2024 American Medical Association.

All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Defense Federal Acquisition Regulation Supplement (FARS/ DFARS) apply.”

The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes:

“Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright © 2024 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.”

Microsoft Corporation requires the following notice in publications containing trademarked product names:

“Microsoft® and Windows® are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries.”

Contents

Volume 1—General Information Welcome—Texas Medicaid Provider Procedures Manual

Contents

Introduction

Section 1: Provider Enrollment and Responsibilities

Section 2: Texas Medicaid Fee-for-Service Reimbursement

Section 3: TMHP Electronic Data Interchange (EDI)

Section 4: Client Eligibility

Section 5: Fee-for-Service Prior Authorizations

Section 6: Claims Filing

Section 7: Appeals

Appendix A: State, Federal, and TMHP Contact Information

Appendix B: HIV/AIDS

Appendix C: Acronym Dictionary

Volume 2—Provider Handbooks Ambulance Services Handbook

Behavioral Health and Case Management Services Handbook

Certified Respiratory Care Practitioner (CRCP) Services Handbook

Children’s Services Handbook

Clinics and Other Outpatient Facility Services Handbook

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook

Health and Human Services Commission Family Planning Program Services Handbook

Healthy Texas Women Program Handbook

Home Health Nursing and Private Duty Nursing Services Handbook

Inpatient and Outpatient Hospital Services Handbook

Medicaid Managed Care Handbook

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook

Medical Transportation Program Handbook

Outpatient Drug Services Handbook

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook

Radiology and Laboratory Services Handbook

School Health and Related Services (SHARS) Handbook

Telecommunication Services Handbook

Vision and Hearing Services Handbook

Introduction

Texas Medicaid Administration The Texas Medical Assistance (Medicaid) Program was implemented on September 1, 1967, under the provisions of Title XIX of the federal Social Security Act and Chapter 32 of the Texas Human Resources Code.

The state of Texas and the federal government share the cost of funding Texas Medicaid. The Health and Human Services Commission (HHSC), the single state Medicaid agency, is responsible for the Title XIX Program. The administration of the program is accomplished through contracts and agreements with the following:

• Medical providers

• Texas Medicaid & Healthcare Partnership (TMHP), the fee-for-service claims administrator

• MAXIMUS, the enrollment broker

• Various managed care organizations (MCOs) and dental managed care organization (dental plans), that administer Medicaid Managed Care benefits.

• The Institute for Child Health Policy (ICHP), the quality monitor

• State agencies

Texas Medicaid providers are reimbursed for services through contracts with health-insuring contractors, fiscal agents, or direct vendor payments.

By signing an HHSC Medicaid Provider Agreement (through the enrollment process) and submitting Medicaid claims, each enrolled provider agrees to abide by the policies and procedures of Medicaid, published regulations, and the information and instructions in manuals, bulletins, and other instruc-tional material furnished to the provider.

Refer to: “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Infor-mation) for addresses and telephone numbers of HHSC and Department of State Health Services (DSHS) regional offices.

SECTION 1: PROVIDER ENROLLMENT AND

RESPONSIBILITIES

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1

OCTOBER 2025

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 OCTOBER 2025

SECTION 1: PROVIDER ENROLLMENT AND

RESPONSIBILITIES

RFP No. HHS0017108 Exhibit D Table of Contents

1.1 Provider Enrollment

1.1.1 Provider Enrollment Revalidation Requirements

1.1.2 NPI and Taxonomy Codes

1.1.3 Online Enrollment

1.1.4 Provider Enrollment Identification

1.1.4.1 Medicare-Only Providers

1.1.4.2 Ordering- or Referring-Only Providers

1.1.4.3 Ordering or Referring-Only Providers Participating in Other State

Health-Care Programs

1.1.4.4 Interns and Medical Residents Who Order, Prescribe, or Refer

1.1.5 Affordable Care Act of 2010 (ACA) Enrollment Requirements

1.1.5.1 Provider Screening Requirement

1.1.5.2 Provider Revalidation

1.1.5.3 Application Fee

1.1.5.4 Ordering- or Referring-Only Providers Search on the Online Provider

Lookup (OPL)

1.1.6 Surety Bond Enrollment Requirement

1.1.6.1 Ambulance Providers

1.1.7 Provider Enrollment Application Determinations

1.1.8 Enrollment in Medicaid Managed Care Programs

1.1.9 Required Enrollment Forms

1.1.9.1 Application Payment Form

1.1.9.2 HHSC Medicaid Provider Agreement

1.1.9.3 Owner/Creditor/Principal Entry

1.1.9.4 Disclosure of Ownership and Control Interest Statement

1.1.9.5 Franchise Tax Account Status Page

1.1.9.6 Certificate of Formation or Certificate of Filing/Articles or Certificate of

Incorporation/Certificate of Fact

1.1.9.7 Copy of License, Temporary License, or Certification

1.1.9.8 Physician’s Letter of Agreement

1.1.9.9 Licensure Renewal

1.1.9.10 Medicare Participation

1.1.9.11 Group Information Changes

1.2 Payment Information

1.2.1 Using EFT

1.2.2 Advantages of EFT

1.2.3 EFT Enrollment Procedures

1.2.4 Receiving Paper Checks

1.2.5 Stale-Dated Checks

1.3 Provider Disenrollment

1.3.1 Excluded Entities and Providers

1.4 Provider Reenrollment

SECTION 1: PROVIDER ENROLLMENT AND RESPONSIBILITIES OCTOBER 2025

1.4.1 Medicare Number

1.4.2 Provider Status (Individual, Group, Performing Provider, or Facility)

1.4.3 Physical Address

1.4.4 Change in Principal Information

1.5 Change of Ownership Requirements

1.6 Claims Filing During Enrollment

1.7 Provider Responsibilities

1.7.1 Compliance with Texas Family Code

1.7.1.1 Child Support

1.7.1.2 Reporting Child Abuse or Neglect

1.7.1.3 Procedures for Reporting Abuse or Neglect

1.7.1.4 Procedures for Reporting Suspected Sexual Abuse

1.7.1.5 Training

1.7.1.6 Reporting Abuse and Neglect of the Elderly or Disabled

1.7.1.7 Procedures for Reporting Abuse or Neglect of the Elderly or Disabled

1.7.2 Texas Medicaid and CHIP Hospital Data Collection and Reporting Requirements

1.7.3 Maintenance of Provider Information

1.7.3.1 Contracted Provider Groups

1.7.3.2 NPI Verification

1.7.3.3 Online Provider Lookup (OPL)

1.7.3.4 Updating NPI and Taxonomy Codes

1.7.3.5 Updating Provider Specialty

1.7.4 Retention of Records and Access to Records and Premises

1.7.4.1 Payment Error Rate Measurement (PERM) Process

1.7.5 Medicare Overpayment

1.7.6 Credit Balance and Recovery Vendor

1.7.7 Release of Confidential Information

1.7.8 Compliance with Federal Legislation

1.7.9 Tamper-Resistant Prescription Pads

1.7.10 Utilization Control — General Provisions

1.7.11 Provider Certification/Assignment

1.7.11.1 Delegation of Signature Authority

1.7.12 Billing Clients

1.7.12.1 Client Acknowledgment Statement

1.7.13 General Medical Record Documentation Requirements

1.7.14 Informing Pregnant Clients About CHIP Benefits

1.7.15 Home Health Providers

1.7.15.1 Home Health Skilled Nursing and Home Health Aide (HHA) Services Provider Responsibilities

1.7.16 Private Duty Nursing (PDN) Providers

1.7.17 Certified Respiratory Care Practitioner (CRCP) Services

1.7.18 Physical, Occupational, and Speech Therapy Providers

1.7.18.1 CCP Enrollment for Children’s Services—20 Years of Age and Younger

1.7.19 Children’s Services Comprehensive Care Program (CCP)

1.7.20 Nondiscrimination for Vaccine Status

1.8 Computer-Based Training Courses for Providers

1.9 Enrollment Criteria for Out-of-State Providers

1.10 Medicaid Fraud, Waste, and Abuse Policy

1.10.1 Reporting Fraud, Waste, and Abuse

1.10.2 Suspected Cases of Provider Fraud, Waste, and Abuse

1.10.3 Employee Education on False Claims Recovery

1.10.4 Managed Care Organization (MCO) Special Investigative Unit (SIU)

1.11 Texas Medicaid Limitations and Exclusions

1.12 Routine Patient Care Costs for Individuals Enrolled in Qualifying Clinical Trials

1.13 Forms

1.1 Provider Enrollment

To be eligible for Texas Medicaid reimbursement, a provider of health-care services (including an out-of-state provider) must:

• Meet all applicable eligibility criteria.

• Be approved by the Texas Health and Human Services Commission (HHSC) for enrollment and enter into a written provider agreement with HHSC.

• Obtain a National Provider Identifier (NPI) from the National Plan and Provider Enumeration System (NPPES).

Refer to: Subsection 1.1.2, “NPI and Taxonomy Codes” in this section.

• File with the Texas Medicaid & Healthcare Partnership (TMHP) the required Texas Medicaid enrollment application ensuring that the application is correct, complete, and includes all required attachments and additional information.

• Provide any additional information requested by TMHP, HHSC, or the HHSC Office of Inspector General (OIG) in connection with the processing of the application.

Providers can use the online Provider Enrollment and Management System (PEMS) tool to enroll electronically through the TMHP website at www.tmhp.com.

Refer to: Subsection 1.1.3, “Online Enrollment” in this section.

After receipt of all information necessary to process the application, the entire application process can typically take up to 60 days. This may be extended in special circumstances. Requests for exceptions to the enrollment process, risk category, and provider types that require additional state approval may extend the length of the application process.

All providers must be enrolled in Texas Medicaid before enrollment can be approved for any other service or program, including, but not limited to, Medicaid managed care.

Certain provider types are required to enroll in Medicare as a prerequisite for enrolling in Texas Medicaid. During the Texas Medicaid enrollment process, with HHSC approval, the Claims Adminis-trator may waive the mandatory prerequisite for Medicare enrollment for certain providers whose type of practice will never serve Medicare-eligible individuals (e.g., pediatrics, obstetrician/gynecologist [OB/

GYN]).

Providers must maintain a valid, current license or certification to be entitled to Texas Medicaid reimbursement. Providers cannot enroll in Texas Medicaid if their license or certification is due to expire within 30 days of application. A current license or certification must be submitted, if applicable.

Refer to: Subsection 1.1.9.7, “Copy of License, Temporary License, or Certification” in this section.

Providers will receive an approval email once the application is completed.

Refer to: Subsection 1.9, “Enrollment Criteria for Out-of-State Providers” in this section for additional criteria that out-of-state providers must meet to enroll in Texas Medicaid.

1.1.1 Provider Enrollment Revalidation Requirements

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 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.

Providers can view and confirm their revalidation date and enrollment information by logging into PEMS. Most providers have an enrollment period of 5 years. Some providers have shorter enrollment periods, which are based on risk categories and other considerations.

Providers can only submit the revalidation application online through PEMS.

https://www.tmhp.com

Enrollment revalidation is available up to 180 days before the revalidation due date. Providers should submit their revalidation applications as soon as they are available so that the process can be completed before the enrollment period ends.

If providers do not complete the revalidation process before the end of their enrollment period, they will be disenrolled. Their claims will not be paid, and their prior authorization requests will be denied. They will not be eligible to participate as a network provider in Medicaid MCOs.

1.1.2 NPI and Taxonomy Codes

The NPI final rule, Federal Register 45, Code of Federal Regulations (CFR) Part 162, established the NPI as the standard unique identifier for health-care providers and requires covered health-care providers, clearinghouses, and health plans to use this identifier in Health Insurance Portability and Accountability Act (HIPAA)-covered transactions. An NPI is a 10-digit number assigned randomly by the NPPES. An NPI must be obtained before a provider can enroll as a Texas Medicaid provider.

PEMS will display the provider types that are eligible to enroll without an NPI.

The Health Care Provider Taxonomy Code Set is an external, non-medical collection of alphanumeric codes designed to classify health-care providers by provider type and specialty. Providers may have more than one taxonomy code. (Taxonomy codes can be obtained from the Washington Publishing Company website at www.wpc-edi.com).

During the enrollment process, providers must select a primary taxonomy code associated with their provider type. Providers will attest with National Plan and Provider Enumeration System (NPPES) the approved Texas taxonomy codes to choose from that correspond to the services rendered by the type of provider they wish to enroll as. Only the code will be displayed. Due to copyright laws, TMHP is unable to publish the taxonomy description. Therefore, providers must verify the taxonomy code associated with their provider type and specialty before beginning the online attestation process.

1.1.3 Online Enrollment

Providers can begin the enrollment process on the Provider Enrollment page of the TMHP website.

Note: All providers must be enrolled in Texas Medicaid before enrollment can be approved for Medicaid Managed Care.

Online enrollment has the following advantages:

• NPI-based enrollment

• A single application for all programs

• A single revalidation date, and/or enrollment period

• Flexible application completion

• The effective date aligns with the approval date

• Paperless

• Consolidated provider agreement

• Email and online communication

• Online help features available

• Enhanced data validation

• 165 cumulative business days will be provided to correct all deficiencies

• Providers are able to edit submitted applications to correct identified deficiencies.

Enrolling online promotes accurate submissions, decreases processing time, and enables immediate feedback on the status of the application.

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1.1.4 Provider Enrollment Identification

PEMS bases each enrollment application on the applying provider’s NPI or API. Provider’s who would like to enroll in Texas health-care programs must do so under one of two categories, individual or organization, determined by their NPI or API.

Individual providers, performing providers, and sole proprietors will enroll in PEMS with an NPI type of Individual.

Facility and group health-care providers who have a single employee or thousands of employees will enroll in PEMS with an NPI type of Organization.

• Individual. This type of enrollment applies to an individual healthcare professional who is licensed or certified in Texas and who is seeking enrollment under the name and social security or tax identi-fication number of the individual. An individual may also enroll as an employee, using the tax identification number of the employer. Certain provider types must enroll as individuals, including:

• Dietitians

• Licensed vocational nurses (LVNs)

• Respiratory care practitioners

• Registered nurses—Comprehensive Care Program (CCP)

• Physical and occupational therapists—CCP

• Speech language pathologists—CCP

• Performing provider. This type of enrollment applies to an individual health care professional who is licensed or certified in Texas, and who is seeking enrollment under a group. The enrollment is under the federal tax identification number of the group, and payment is made to the group. If a health-care professional is required to enroll as an individual, as explained above, but the person is an employee and payment is to be made to the employer, the health-care professional does not enroll as a performing provider. Instead, the health-care professional enrolls as an individual provider under the federal tax identification number of their employer. Providers are encouraged to submit performing provider applications through a Group Initiated request.

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

During the enrollment process, the available taxonomy code list is populated with either taxonomy code 193200000X or 193400000X for a clinic/group practice, depending on which specialty is chosen. Case Management for Children and Pregnant Women (CPW) providers enrolling as a group should use taxonomy code 251B00000X. The taxonomy codes for clinic/group practice providers are accurate and have been approved by HHSC. The most appropriate taxonomy codes should be selected for any performing providers that will be enrolled according to their specific performing provider type and specialty.

• 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. For this reason, facility enrollment does not require enrollment of performing providers. The following facility enrollment types require the disclosure of a Supervising Licensed Practitioner (SLP):

• Family Planning Enrollment

• Hearing Aid Enrollment

• Independent Lab Enrollment

• Texas Health Steps Medical (THSteps Medical) Enrollment

• The following provider types must enroll as facilities:

• Ambulance and air ambulance

• Ambulatory surgical center (ASC) and hospital-based ambulatory surgical center (HASC)

• Birthing center

• Catheterization lab

• Chemical dependency treatment facility (licensed by the Texas Commission on Alcohol and Drug Abuse)

• Consumer Directed Services Agency

• County Indigent Health Care Program

• Community mental health center

• Comprehensive health center

• Comprehensive outpatient rehabilitation facility/outpatient rehabilitation facility

• Durable medical equipment (DME)

• Early Childhood Intervention

• Federally Qualified Health Center (FQHC)

• Freestanding psychiatric facility

• Freestanding rehabilitation facility

• Home and Community Based Services – Adult Mental Health (HCBS-AMH) providers

• Home Health/Home and community support services agency

• Hospital/critical access hospital/out-of-state hospital

• Military hospital

• Hyperalimentation

• Independent diagnostic testing facility/physiological lab

• Indian Health Services

• Independent laboratory

• Intellectual or developmental disability (IDD) case management

• Local health department

• Maternity services clinic

• Mental health targeted case management and mental health rehabilitative services

• Milk bank donor

• Personal care services

• Pharmacy

• Portable X-ray

• Prescribed Pediatric Extended Care Centers (PPECC)

• Radiation treatment center

• Radiological laboratory

• Renal dialysis facility

• Rural health clinic (RHC)

• School health and related services (SHARS)/non-school SHARS

• Service responsibility option

• Skilled nursing facility

• State Supported Living Center (SSLC)

• Vision medical supplier

• Women, Infant and Children

Providers can submit one request to enroll several different provider types and specialty combinations.

A unique provider identifier will not be assigned. Providers are encouraged to submit performing provider applications through a Group Initiated request.

Refer to: Subsection 1.10, “Medicaid Fraud, Waste, and Abuse Policy” in this section for additional information.

1.1.4.1 Medicare-Only Providers

The Medicare-only provider type can be used by providers that only render Medicare services not covered by Texas Medicaid (Medicare-only services) or that have a provider type not recognized by Texas Medicaid. Providers that are currently enrolled in Texas Medicaid or providers that render, refer, or prescribe Medicaid services are not eligible to enroll as Medicare-only providers.

1.1.4.2 Ordering- or Referring-Only Providers

Individual providers who are not currently enrolled in Texas Medicaid and whose only relationship with Texas Medicaid is to order or refer for supplies or services for Texas Medicaid-eligible clients must enroll in Texas Medicaid as participating providers. This requirement is in accordance with provisions of the Affordable Care Act of 2010 (ACA), 42 CFR §455.410(b), which requires all fee-for-service (FFS) and managed care network ordering or referring physicians or other professionals who order or refer for supplies or services under the Medicaid State plan, or under a waiver of the plan, to enroll in Medicaid as participating providers.

Providers who are out of network for Medicaid managed care organizations (MCOs) do not need to enroll as ordering or referring-only providers. The enrollment requirement includes providers who order or refer for supplies or services for dually eligible clients (i.e., clients who are enrolled in both Medicare and Medicaid), as the client’s claims would be considered Medicaid claims. These providers can enroll online using PEMS.

Important: Individual providers who are currently enrolled in Texas Medicaid or the CSHCN Services Program and who currently have an active Texas Medicaid or CSHCN Services Program enrollment can use their current enrollment for ordering or referring services and do not need to obtain a separate ordering and referring enrollment. An acute care billing provider’s practice location will be deactivated if the provider enrolls as an ordering-only or referring-only provider.

Providers who enroll in Texas Medicaid as ordering or referring-only providers are not required to submit a separate enrollment to order and refer for both Texas Medicaid clients and CSHCN Services Program clients. Although ordering or referring-only providers do not submit claims to TMHP for rendered services, the ordering or referring-only provider’s NPI is required on claims that are submitted by the billing providers that render the services or provide the supplies or services.

Refer to: Subsection 6.4.2.4, “Ordering or Referring Provider NPI” in “Section 6: Claims Filing” (Vol.

1, General Information) for information about filing claims that require an ordering- and referring-only provider NPI.

1.1.4.3 Ordering or Referring-Only Providers Participating in Other State Health- Care Programs

Providers who order or refer for supplies or services for Children’s Health Insurance Program (CHIP) clients must enroll as a participating providers with TMHP. Providers who are out of network for CHIP MCOs do not need to enroll as ordering or referring-only providers. Providers who order or refer for supplies or services for Healthy Texas Women (HTW) and CSHCN clients must also enroll as partici-pating providers with TMHP.

1.1.4.4 Interns and Medical Residents Who Order, Prescribe, or Refer Interns and medical residents with only Physician-In-Training (PIT) permits issued by the Texas Medical Board cannot enroll in Texas Medicaid. An intern or resident’s licensed supervising physician must be reported as the ordering or referring provider on claims that are generated from the order or referral of the intern or resident. The NPI of the supervising physician must be listed on orders or referrals written by the interns or residents they supervise. The licensed supervising physician must be enrolled in Texas Medicaid as a billing provider or as an ordering or referring-only provider.

1.1.5 Affordable Care Act of 2010 (ACA) Enrollment Requirements Providers are required to fulfill certain requirements for enrollment in order to comply with the provi-sions of ACA. Providers that are enrolled in Texas Medicaid and have fulfilled the ACA requirements through their Texas Medicaid enrollment are considered ACA-compliant for all programs in which they are enrolled.

Refer to: TMHP website at www.tmhp.com for additional information about ACA requirements.

In accordance with Section 6401 of ACA, the following requirements apply:

• Upon initial enrollment, revalidation, and re-enrollment, all participating providers are screened based on their categorical risk level. (complies with 42 CFR §§455.410 and 455.450)

• All providers are required to revalidate at least every three to five years based on provider type.

• Institutional providers who are enrolling, revalidating, or reenrolling are required to pay an appli-cation fee if one has not already been paid to Medicare or another state’s Medicaid program or

CHIP.

• Ordering and referring-only providers are required to enroll in Texas Medicaid as participating providers.

Refer to: Subsection 1.1.4.2, “Ordering- or Referring-Only Providers” in this section.

1.1.5.1 Provider Screening Requirement

In compliance with ACA, all providers must be screened, which includes:

• Providers who submit a provider enrollment application for new enrollment or other type of enrollment or reenrollment.

• Providers who are currently enrolled in Texas Medicaid and are required to revalidate their enrollment in Texas Medicaid.

1.1.5.2 Provider Revalidation

In compliance with the 42 CFR §455.414, all providers are required to revalidate at least every three to five years:

• DME providers are required to revalidate enrollment information at least once every five years.

• All other provider types must revalidate their enrollment information at least once every five years.

Group administrators may submit enrollment revalidations for performing providers in a group.

During revalidation, the provider screening will be repeated.

1.1.5.3 Application Fee

Under ACA, institutional providers are subject to an application fee for applications, including initial applications, applications for new practice locations, revalidation, and reenrollment applications. Upon completion of the PEMS online application, providers will be notified whether they are required to pay an application fee. The amount of the application fee is subject to change every calendar year.

Providers can refer to the TMHP website for the list of provider types that are required to pay the appli-cation fee.

Note: Providers that are required to pay the application fee but have already paid the fee to Medicare or another state’s Medicaid program or CHIP have fulfilled the fee requirement and do not have to submit the fee to Texas Medicaid. Proof of payment must be submitted with the application. Providers who are enrolled in Medicare must provide documentation that specifies whether or not they have completed the ACA rescreening process with Medicare.

1.1.5.4 Ordering- or Referring-Only Providers Search on the Online Provider Lookup (OPL)

Providers can verify that an ordering- or referring-only provider is enrolled in Medicaid by using either the basic or advanced provider search function of the OPL.

1.1.6 Surety Bond Enrollment Requirement

All newly enrolling and re-enrolling DME and nongovernment-operated ambulance providers must obtain a surety bond that complies with 1TAC §352.15 as a condition of enrollment and continued participation in Texas Medicaid.

DME providers can refer to subsection 2.1.2, “Surety Bond Requirements” in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks).

Ambulance providers can refer to subsection 1.1.6.1, “Ambulance Providers” in this handbook.

Important: Surety bonds obtained for the purpose of accreditation in the Medicare program, which lists the Centers for Medicare & Medicaid Services (CMS) as obligee, do not fulfill the surety bond requirement for Texas Medicaid.

The surety bond submitted to Texas Medicaid must meet the following requirements:

• A bond in an amount of no less than $50,000 must be provided for each enrolled location.

• The bond must be submitted on the State of Texas Medicaid Provider Surety Bond Form. No other form will be accepted. The use of this form designates HHSC as the sole obligee of the bond. Instruc-tions are included with the form.

• The bond must be issued for a term of 12 months. Bonds for longer or shorter terms are not acceptable.

• The bond must be in effect on the date that the provider enrollment application is submitted to TMHP for consideration. The effective date stated on the bond must be:

• No later than the date that the provider enrollment application is submitted.

• No earlier than 12 months before the date that the provider enrollment application is submitted.

https://www.tmhp.com/sites/default/files/provider-forms/provider-enrollment/F00092_Texas_Medicaid_Provider_Surety_Bond.pdf

• The bond must be a continuous bond. A continuous bond remains in full force and effect from term to term unless the bond is canceled.

Important: An annual bond that specifies effective and expiration dates for the bond is not acceptable.

At the time of enrollment, revalidation, or reenrollment, providers must submit a copy of the surety bond form with signatures and a copy of the Power of Attorney document from the surety company that issued the bond.

Note: Surety companies may refer to Texas Department of Insurance (TDI) file #9212562912 or TDI link #132456 when filing the bond.

DME and non-government-operated ambulance providers must maintain a current surety bond to continue participation in Texas Medicaid. To avoid losing Medicaid enrollment status, providers must submit proof of continuation to TMHP Provider Enrollment before the expiration date of the bond currently on file. The completed proof of continuation document must include the bond number, original signatures of the authorized corporate representative of the DME or ambulance provider (principal), the attorney-in-fact of the surety company, date of the original bond, and new “good through” date. Providers may upload a proof of continuation by initiating a Maintenance - Practice Location - Surety Bond Request in PEMS.

Refer to: The State of Texas Medicaid Provider Surety Bond Form in the Forms section of the TMHP website at www.tmhp.com.

1.1.6.1 Ambulance Providers

Ambulance providers that participate in Texas Medicaid fee-for-service, managed care programs, or the CHIP must, as a condition of emergency medical services (EMS) provider license renewal, obtain a surety bond that complies with 1 TAC §352.15 and submit the bond to TMHP according to the require-ments listed above. A copy of the bond must be included with their application to the Department of State Health Services (DSHS) to renew their emergency services provider license.

Providers can refer to the DSHS website for additional information.

Ambulance providers that are directly operated by a governmental entity are exempt from the surety bond requirement.

1.1.7 Provider Enrollment Application Determinations

An application for provider enrollment may be approved with conditions, or denied. The provider applicant is issued a notice of the enrollment determination.

Refer to: Subsection 1.1.5, “Affordable Care Act of 2010 (ACA) Enrollment Requirements” in this section for additional information about the ACA 3- to 5-year revalidation requirement.

When an application for enrollment is approved with conditions, the applicant has no right of appeal or administrative review of the enrollment determination. The types of conditional enrollment include, among other things:

• An application may be approved for time-limited enrollment, meaning the provider is granted a contract to participate in Medicaid for a specific period of time. In this case, the provider is sent a notice that includes the deactivation date of the contract. It is the provider’s responsibility, if the provider chooses to seek continued Medicaid participation, to file a complete and correct revali-dation application before the deactivation date of the provider’s current contract. It is recommended that the provider submit a revalidation application at least 60 days before the current contract deactivation date, to ensure that the application is complete and correct before the deacti-vation date. This may avoid a lapse between the provider’s current contract and the new contract, if a new contract is granted.

CPT ONLY - COPYRIGHT 2024 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

https://www.tmhp.com/sites/default/files/provider-forms/provider-enrollment/F00092_Texas_Medicaid_Provider_Surety_Bond.pdf

• An application may be approved subject to restricted reimbursement, meaning the provider is eligible to have only certain types of claims paid. This includes, among other things, reimbursement of only Medicare crossover claims (i.e., claims with respect to “dual eligible” recipients who are covered by both Medicare and Medicaid).

An application might be denied. If an application is denied, TMHP will send the provider a denial notice that explains the basis for the denial. The notice also explains the provider’s right to make a request for an informal desk review of the denial decision and the procedures for filing such a request. The admin-istrative rules governing a request for an informal desk review of the denial decision are found in the following TAC rules:

• 1 TAC § 371.1015(b). If the application is denied based upon the OIG’s recommendation, an informal desk review request must be in writing (through PEMS), received within 20 business days of the date on the letter, and filed in accordance with the instructions provided in the denial notice.

• 1 TAC § 352.11(d)(2)(A). If the application is denied for any other reason, an informal desk review request must be in writing (through PEMS), received within 30 calendar days of the date on the letter, and filed in accordance with the instructions provided in the denial notice.

HHSC will conduct the informal desk review and render a final enrollment determination. HHSC’s final determination is not subject to further administrative review or reconsideration.

The enrollment date is the day on which a new NPI was enrolled. This date impacts claims filing deadlines.

Refer to: Subsection 6.1.4.2, “Claims for Newly Enrolled Providers” in “Section 6: Claims Filing” (Vol. 1, General Information) for timely-filing guidelines for newly enrolled providers.

HHSC determines the enrollment effective dates for providers that choose to enroll in Medicaid and Texas State Health-Care Services. Enrollment notification letters that contain the enrollment infor-mation for newly enrolling providers are emailed the following day. Revalidation notifications that contain the updated revalidation due date are sent by email and posted to the provider’s MyAccount dashboard.

1.1.8 Enrollment in Medicaid Managed Care Programs

To be reimbursed for services rendered to Medicaid managed care clients, providers must be enrolled in Texas Medicaid and then must enroll with the client’s health plan to be eligible for reimbursement for services rendered.

Refer to: Subsection 2.2, “Provider Enrollment and Responsibilities” in the Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

1.1.9 Required Enrollment Forms

To enroll in Texas Medicaid, providers must complete all sections of the Texas Medicaid Enrollment Application through PEMS.

Providers can refer to the TMHP Provider Enrollment and Management System instructional website for information about required forms and other documentation. This website explains, by provider type, the documents and information that must be provided with the application.

Refer to: https://www.tmhp.com/topics/provider-enrollment/pems/start-application

When prompted to enter a tax identification number (tax ID) on the electronic copy of an enrollment application, the applicant should list the entity’s nine-digit federal tax identification number.

Providers can call the TMHP Contact Center at 1-800-925-9126 for help with completing the application.

https://www.tmhp.com/topics/provider-enrollment/pems/start-application

Providers will be notified of incomplete applications and will have 30 business days to provide the requested missing information. If the information is not provided within 30 business days, TMHP will terminate the enrollment process. If the provider wants to enroll at a later date, a new enrollment appli-cation must be submitted. Providers are required to review their enrollment application for correctness and completeness before submitting it to TMHP.

By e-signing the HHSC Medicaid Provider Agreement, a provider is certifying that all information submitted in connection with the application for enrollment is complete and correct. Any false, misleading, or incomplete information submitted in connection with an enrollment application consti-tutes a Medicaid program violation, and may result in administrative, civil, or criminal liability.

Refer to: Subsection 1.10, “Medicaid Fraud, Waste, and Abuse Policy” in this section.

1.1.9.1 Application Payment Form

All providers who are required to pay an application fee to participate in the Medicaid program must fill out the Application Fee page during enrollment. The application cannot be processed if the application fee is required and is not submitted with the application.

Refer to: Subsection 1.1.5.3, “Application Fee” in this section.

1.1.9.2 HHSC Medicaid Provider Agreement

The HHSC Medicaid Provider Agreement must be submitted by all providers who enroll in Texas Medicaid and must be signed by the provider who is applying for enrollment. If the applicant is an entity, a principal of the entity who has the authority to bind the entity to the requirements of the HHSC Provider Agreement must sign the agreement. “Principal” is defined in the following section.

If the provider is city- or government-owned, the agreement must be signed by a person who is autho-rized under the city or government charter. This form is an agreement between HHSC and the provider performing services under the State Plan wherein the provider agrees to certain provisions as a condition of participation.

Note: The person who signs the HHSC Enrollment Agreement is certifying that all of the infor-mation in the application packet, including every completed Owner/Creditor/Principal entry, is complete and correct. This includes a certification that every person who is required to complete an Owner/Creditor/Principal entry has done so, and all required Owner/Creditor/ Principal entries are included with the application.

1.1.9.3 Owner/Creditor/Principal Entry

An Owner/Creditor/Principal entry must be completed by each principal/creditor, subcontractor, and creditor of the provider that is applying for enrollment with the following exceptions:

• Performing providers who are applying to join a group that is already enrolled

• Individuals who enrolled using their own Social Security number and an entity type of Individual/ Sole Proprietorship

Principals of the provider include all of the following:

• An owner with a direct or indirect ownership or control interest of 5 percent or more

• Corporate officers and directors

• Managing employees or agents who exercise operational or managerial control, or who directly or indirectly manage the conduct of day-to-day operations

• Limited or nonlimited partners

• Shareholders of a professional corporation, professional association, limited liability company, or other legally designated entity

• Any employee of the provider who exercises operational or managerial control over the entity or who directly or indirectly conducts the day-to-day operations of the entity

• All individuals, companies, firms, corporations, employees, independent contractors, entities, or associations that have been expressly granted the authority to act for or on behalf of the provider

• All individuals who are able to act on behalf of the provider because their authority is apparent

• An individual or entity with a security interest in a debt that is owed by the provider if the creditor’s security interest is protected by at least 5 percent of property listed in Section III(c) of the Disclosure of Ownership

A subcontractor of the provider is defined as follows:

• An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or

• An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies

Note: This includes the on-site manager, supervising licensed practitioner, or medical director for each physical location of the provider in Texas.

1.1.9.4 Disclosure of Ownership and Control Interest Statement All providers must submit the Disclosure of Ownership and Control Interest Statement as part of the enrollment application, with the following exceptions:

• Performing providers who are applying to join a group that is already enrolled

• ECI, MHMR, MHR, Blind Children’s Vocational Discovery & Development Program, YES Waiver, TB Clinic, Military Hospital, State Hospital or SHARS providers

This form also contains questions that must be answered under federal law. Failure to provide complete and accurate information as instructed on this form will constitute an incomplete application, which may result in denial of enrollment. Incomplete or inaccurate information on this form constitutes a violation of the rules of Medicaid and may also result in administrative, civil, or criminal liability.

Providers that dually participate in Medicare and Medicaid, are expected to make accurate and consistent disclosures of ownership and managing staff to each program pursuant to federal regulations at §§ 420.202 through 420.206.

Refer to: Subsection 1.10, “Medicaid Fraud, Waste, and Abuse Policy” in this section.

Note: Providers are required to submit any change in ownership, corporate officers, or directors to TMHP Provider Enrollment within 30 calendar days of the change.

Refer to: Subsection 1.7.3, “Maintenance of Provider Information” in this section.

1.1.9.5 Franchise Tax Account Status Page

When enrolling as a “Corporation” type of entity, providers must submit a Franchise Tax Account Status Page. This information can be obtained from the Texas State Comptroller’s Office website at:

https://mycpa.cpa.state.tx.us/coa/

Providers who have a 501(c)(3) Internal Revenue Exemption are not required to submit the Franchise Tax Account Status Page, but they must submit the IRS exemption letter.

1.1.9.6 Certificate of Formation or Certificate of Filing/Articles or Certificate of Incorporation/Certificate of Fact

When enrolling as a “Corporation” type of entity, providers must submit the Certificate of Formation or Certificate of Filing form. Obtain the form from the Office of the Secretary of State of Texas. The name on this form must exactly match the legal name shown on the W-9 form.

https://mycpa.cpa.state.tx.us/coa/

The following certificates also apply for corporations:

• For corporations formed prior to January 1, 2006, Articles or Certificate of Incorporation/Certif-icate of Authority/Certificate of Fact

• For corporations formed on or after January 1, 2006, Certificates of Formation or Certificate of Filing

• For corporations registered in a state other than Texas, Certificate of Authority or Certificate of Filing

The Certificate and any required certifications to provide certain services in Texas must be submitted when a corporation is registered in a state other than Texas. The form identifies the legal name of the corporation and is proof that the corporation is registered to do business in Texas.

Note: Out-of-state providers that do not provide services in the state of Texas are exempt from submitting this form.

1.1.9.7 Copy of License, Temporary License, or Certification

Providers cannot enroll in Texas Medicaid if their license is due to expire within 30 days. During the enrollment process, TMHP verifies licensure using available resources. If TMHP cannot verify a license at the time of enrollment, it is the providers’ responsibility to provide a copy of the active license to

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