Serving as a Medicaid provider of children’s health services brings both professional and personal rewards. Texas has a great need for health-care providers who can deliver quality care to the infants, children and adolescents who are the state’s future. As a provider, you have the opportunity to help youth establish healthy behaviors and to nurture a trusting provider-patient relationship that supports good health. In order to be reimbursed for Medicaid services, eligible providers must complete an application and provider agreement with HHSC and then enroll in Texas Medicaid. After completing that process, providers who want to be in a managed care network(s) must also be contracted with and credentialed by the respective plan(s). Managed care enrollment is covered later in this section. The Texas Medicaid & Healthcare Partnership (TMHP) administers the enrollment process for Medicaid providers. Providers in managed care networks are enrolled in both Medicaid managed care and FFS by TMHP.
HHSC and the TMHP require online enrollment in Texas Medicaid using the Provider Enrollment and Management System (PEMS), which offers a step-by-step guide.
Entities that may enroll as Medicaid facilities include:
A full list of individuals and entities that may enroll in Medicaid and their eligibility qualifications can be found in the PEMS.
Individual health-care professional licensed or certified in Texas
May also enroll as a performing provider
Health-care items or services provided under the auspices of a legal entity. Individuals providing the items or services must be certified or licensed in Texas
Individual health-care professional licensed or certified in Texas and enrolled under a group
Legal entity licensed or certified
Even if they do not provide direct care, FFS and managed care network providers who order, refer or prescribe for individuals enrolled in Medicaid must be enrolled as Medicaid providers. The only exception is that out-of-network providers who order, refer or prescribe only for patients enrolled in managed care plans are not required to enroll as Medicaid providers.
Providers who enroll with Texas Medicaid must submit a separate Provider Enrollment Application for each enrollment type requested. For example, a physician already enrolled as an individual who wishes to bill for services provided in connection with a group must submit a separate enrollment application and be approved as a performing provider with the group.
After receipt of all necessary information, the processing can take up to 60 days, or longer in special circumstances.
If you provide Medicaid services to patients before your Texas Medicaid enrollment is complete, there is no guarantee an application will be approved for reimbursement after processing. If the application is denied, claims will not be payable by Medicaid. You are prohibited from billing the patient for those Medicaid services.
In addition to Medicaid enrollment, providers who want to participate in the STAR Medicaid, STAR Kids, STAR Health, dual Medicare-Medicaid, and/or STAR+PLUS medical and dental plans must complete a separate contract and credentialing application with each medical and dental plan. Providers must be enrolled in Texas Medicaid before they can be contracted and credentialed by a medical or dental plan. Generally, credentialing involves verification of qualifications and practice history, including an examination of appropriate licensure, sanctions, limits on licensure and malpractice history. The managed care credentialing process must be completed before the start date of a contract between the medical plan and an individual provider.
Providers must enroll online by using the Provider Enrollment and Management System (PEMS). Upon completion of the Texas Medicaid provider application, qualified providers are automatically enrolled as Texas Health Steps medical checkup providers and CSHCN Services Program providers unless they choose to opt out of one or both as prompted in the application. Providers who opt out can enroll in the CSHCN Services Program and in Texas Health Steps at a future date using PEMS. The enrollment process requires completion of the following forms:
| Provider Information Form (PIF-1) | All providers applying for Texas Health Steps enrollment more than one year from their Texas Medicaid enrollment date |
| Principal Information Form (PIF-2) | Each principal of all providers applying for Texas Health Steps enrollment more than one year from their Texas Medicaid enrollment date |
| Disclosure of Ownership Form | All providers applying for Texas Health Steps enrollment more than one year from their Texas Medicaid enrollment date |
| W-9 Request for Taxpayer Identification Number and Certification | All providers |
| EFT Agreement | Electronic Funds Transfer |
All forms can be submitted through the online PEP tool. A paper enrollment application can be downloaded from the TMHP provider website or requested by calling 800-925-9126.
Pharmacy providers who want to participate in the Medicaid VDP must be enrolled prior to providing outpatient prescription services. Pharmacy providers must also be enrolled with VDP before participating in any Medicaid managed care network.
In order to provide medically necessary drugs and supplies, a pharmacy provider must enroll in the Comprehensive Care Program (CCP). To participate as a durable medical equipment (DME) provider, the pharmacy must complete a separate DME application. The pharmacy provider must first be enrolled in VDP.
The first step for enrollment is to complete the TVFC Program Agreement, which must be updated each year to maintain enrollment. The agreement form, which is available for download on the Texas Department of State Health Services Immunization Unit web page, includes basic information about the site and outlines the signing clinician’s responsibilities. TVFC-enrolled sites must also enroll in the Texas Immunization Registry. Prior to receiving TVFC vaccines, all new sites must receive an enrollment visit.
The TVFC and Adult Safety Net Provider Manual, which can be downloaded from the TVFC web page, contains comprehensive details on enrollment and program requirements.
To use the RDS, providers, hospitals and other health facilities must complete and return the Laboratory’s Facility Security Agreement form. Each person who will have access to the system is required to complete and submit the Remote User Security Rights and Confidentiality Form.
The ID number and security forms can be downloaded from the online Laboratory Testing Services Manual, which is accessible from the Appendix.