Texas Medicaid Provider Enrollment Portal

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Maternal & Child Health Information

For important information from the Texas Department of State Health Services on Maternal & Child Health and the formula shortage, visit dshs.state.tx.us/mch.

American Rescue Plan Act Resources for Home and Community-Based Services

• 05.19.2022 – HHSC Alert: American Rescue Plan Act Home and Community-Based Services Provider Retention Payments Attestation and Initial Reporting

We know you don’t have time to spare, so we put all the UnitedHealthcare Community Plan resources you need in one place. Use the navigation on the left to quickly find what you’re looking for. Be sure to check back frequently for updates.

Checklist Of Documents Required To Complete Credentialing:

• Complete the Individual and Group Provider Credentialing Application
• Copy of Professional License
• Copy of Certificate of Professional Liability Insurance
• Disclosure of Ownership and Control Interest Statement
• Copy of DEA Certificate, if appliable
• Collaborating Physician Form, if applicable
• Supervising Physician Form, if applicable
• Copy of Clinical Laboratory Improvement Amendments , if applicable
• Accreditation/Site Visit/Rural County/CMS Letter, if applicable
• Central Registry Check Request for Abuse/Neglect – Form 1600, for behavioral health foster care providers only

For questions on the credentialing process,please:

Nursing Facility Services And Icf/iid Services

New NF and ICF/IID applicants enroll in Texas Medicaid in addition to the HHSC Regulatory Services licensing and HHSC contracting process. New applicants must complete Texas Medicaid enrollment through PEMS and provide verification of enrollment to HHSC. Other forms and documents must also be included in the application packets for a license and a contract from HHSC. For more information, visit the How To Become a Nursing Facility Provider or the How to Become an ICF/IID Provider webpages at the HHS website.

The mailing address for HHSC license application packets is:Texas Health and Human Services ARTSMail Code 1470P.O. Box 149055Austin. TX 78714

• Questions regarding HHSC process for nursing facility services may be submitted to .
• Questions regarding HHSC process for ICF/IID services may be submitted to .

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Welcome Texas Medicaid Providers

WARNING: THIS IS A TEXAS HEALTH AND HUMAN SERVICES INFORMATION RESOURCES SYSTEM THAT CONTAINS STATE AND/OR U.S. GOVERNMENT INFORMATION. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW.———————–AMA/ADA End User License AgreementLICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION

CPT only copyright 2021 American Medical Association. ALL rights reserved. CPT is a registered trademark of American Medical Association.

You, your employees and agents are authorized to use CPT only as contained in materials on the Texas Medicaid & Healthcare Partnership website solely for your own personal use in directly participating in healthcare programs administered by THHS. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

U.S. Government Rights

Disclaimer of Warranties and Liabilities

Promoting Continuity Of Care

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When families are faced with unemployment or loss of employer-based health coverage, they turn to Texas Medicaid or another health-care program to provide the health care they and their loved ones need. Providers who enroll as Texas Medicaid and other state health-care programs providers can continue to see existing patients during those times of change.

Providers may also render service to families with mixed coverage .

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Contracted Medical Or Ancillary Providers

Contracted providers can use this form to add a product, provider or location to an existing contract. Please note, if you are affiliated with a third party Delegate Manager, all changes must be made at the request of the Delegate. Contact your Delegate Manager for additional information.

NOTE: The following requests should be submitted by contacting your Account Management Representative.

• Medical Providers and Groups who want to add a new practice location and are currently credentialed by Superior or
• Ancillary providers who want to add a new practice location that will operate under the same state license and TIN/NPI combination.

, or visit Superior’s Provider Resources webpage to review a current listing of additional information.

Filing Claims For Managed Care Services

Claims for services administered by a medical or dental plan must be submitted to the plan. Providers may submit managed care claims by the following:

• Submit acute, long term services or dental claims directly to the appropriate medical or dental plan using the methods established by the plan.
• Submit acute care or dental claims electronically to TMHP for routing to the appropriate medical or dental plan.

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Coming Soon: Tmhp Provider Enrollment And Management System

Date:10/21/21

The Texas Medicaid & Healthcare Partnerships Provider Enrollment and Management System is coming soon. Provider enrollment functions will be available through PEMS, and providers must use the new system to enroll in Texas Medicaid. The new system will be the single tool for provider enrollment, reenrollment, revalidation, and maintenance requests .

PEMS BenefitsUsing PEMS will result in the following benefits:

• PEMS eliminates the need for multiple Texas Provider Identifiers , allowing providers to interact with all Texas Medicaid records in a single, easy-to-use system.
• PEMS will allow for Texas Medicaid enrollment in multiple state healthcare programs from a single application. Real-time data validation will reduce errors and expedite the enrollment process.
• The message dashboard will provide timely online email notifications and related correspondence.
• PEMS will offer real-time availability to changes made to provider information and offer instant access to the status of provider enrollment applications.
• PEMS will allow clients to locate providers faster with the expanded Online Provider Lookup search functionality.

Please note: Providers should plan for the following changes on December 13, 2021:

Applicant’s Instructions For Completing Form 3684

Note: Applicants that bill or intend to bill acute care services through Texas Medicaid & Healthcare Partnership must enroll in Texas Medicaid through TMHP. For more information, visit the Texas Health and Human Services website. Click on “Doing Business With HHS” at top of web page and then click on “Medicaid Provider Enrollment” under Texas Medicaid.

Carefully read the following instructions. Errors and omissions will cause delays in processing.

Section 1. Type of Enrollment Check the New Enrollment box if you are a new applicant.

Check the Re-enrollment box if you are an existing HHS provider that is submitting an enrollment application before the end of your current enrollment period.

Section 2. Legal Entity Information

Name of Legal Entity Enter the full legal name of the entity, exactly as it was chartered, filed, registered or otherwise legally declared. If the applicant is an individual, enter their full legal name.

Doing Business As If applicable, enter the d/b/a relevant to this legal entity.

Federal Tax ID Number Enter the employer identification number assigned to the legal entity by the Internal Revenue Service . If the legal entity is a sole proprietorship or individual who does not have an EIN, enter the owner’s or individual’s Social Security number .

National Provider Identifier Enter the NPI number issued to the legal entity by the National Plan and Provider Enumeration System .

Legal Entity Physical Address Self-explanatory.

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Texas Medicaid And Healthcare Partnership

TMHP processes claims for Texas Medicaid and other state programs. As claims administrator, TMHP processes claims for Medicaid services provided in the traditional, fee-for-service system. TMHP does not process claims for services provided by Medicaid managed care organizations , but does collect encounter data from MCOs for use in evaluation of quality and utilization of managed care services.

Contractor Enrollment Process & Requirements

Note: An applicant seeking to obtain a contract must enroll in Texas Medicaid. Please visit the Medicaid Provider Enrollment web page to review the enrollment process.

Health and Human Services has 1 standard contract and enrollment application for all Community Services providers. The application packet is comprised of a number of different forms and required documents.

The enrollment process for contract applications takes approximately 60 days from the date your complete application is received by HHS. It is crucial that you document all required information completely and accurately. The application process will be delayed if your application is returned for corrections. Your application will be processed in the order received by HHS. The effective date of the contract will be determined by HHS, but will be no earlier than the first day of the month following the month after the application has been fully completed and executed. Some regions and programs have long interest lists. Contracting with HHS does not guarantee that a provider agency will receive referrals.

Applicants seeking to obtain contracts for the following programs must have a current license as described below. An HHS Home and Community Support Services Agency license must have the appropriate category required for the contract as described below:

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Dhp Offering Cultural Competency Training Available For Providers

What is cultural competency and why does it matter to you or healthcare? Providers are providing care to diverse patients and their families. Effective communication between the provider and the member leads to better health outcomes. In addition, provider cultural competency supports unbiased quality care and delivery of care that is respectful of the beliefs, and cultural and linguistic needs of diverse patients while also reducing health disparity and improving access to high-quality care.

DHP is promoting THSteps and other providers to take advantage of the Health and Human Services Texas Health Steps Culturally Effective Heath Care CE Online course. HHS is offering 1.00 CE hours for the completion of this course.

Managed Care Contact Information

Medicaid providers, including pharmacies, who want to contract with a medical or dental managed care plan must contact the managed care organization of their choice to complete a separate contract and credentialing application in addition to enrolling with TMHP. For MCO provider representative contact information, go to the Managed Care Organization & Dental Maintenance Organization Provider Services Contact Information webpage.

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Tmhp Application Fee For Ltc Providers

Texas Medicaid must comply with 42 CFR §455.460, which requires states to collect an applicable application fee from a prospective or re-enrolling provider. The amount of the application fee is subject to change every calendar year. Each year, the Centers for Medicare & Medicaid Services publishes the application fee in the Federal Register 60 days before the new calendar year.

• The fee for calendar year 2022 is $631.
• The fee for calendar year 2021 is $599.
• The fee for calendar year 2020 is $595.
• The fee for calendar year 2019 is $586.
• The fee for calendar year 2018 is $569.
• The fee for calendar year 2017 is $560.

Payment must be made through PEMS.

Dhp Pcp Incentives Provider Advisory Comments Q& a Offered Both In

Claim Appeals may be submitted via:

• DHP Provider Portal

You may also submit your Claim Appeal by mail:

Claims Administration

Phone Number: 1-877-220-6376 or 1-855-425-3247 Fax Number: 361-808-2725Email:

Once you have gone through the Driscoll Complaint Process, and you are not pleased with the response, you may file your complaint directly to the Health and Human Services Commission by calling toll-free 1-866-566-8989. If you would like to make your complaint in writing, please send it to the following address:

Texas Health and Human Services CommissionHealth Plan Operations H-320P.O. Box 85200Austin, TX 78708-5200

If you can get on the internet, you can send your complaint in an email to

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Clinical And Administrative Advisory Committee Behavioral Health Advisory Committee Perinatal Advisory Committee

These Provider Advisory Groups provide recommendations to Texas Childrens Health Plan in the following areas:

• Identification and review of clinical practice guidelines and prior authorization guidelines
• Review of general utilization patterns and assessment of Provider compliance with clinical guidelines
• Recommendations for member engagement and quality improvement programs to improve health outcomes and keep members healthy
• Strategies and recommendations for improving Health Plan administrative processes
• Recommendations on how to improve care based on Member feedback and their personal experiences serving our Members and
• Opportunities for connecting network Providers and Managed Care Organization clinical experts for purposes of peer support and sharing best practices.

There is a Clinical and Administrative Advisory Committee for each of our three Service Areas:

The Behavioral Health Advisory Committee and Perinatal Advisory Committee meet in the Harris Service Area.

The meeting cadence for each of the committees are as follows:

• Clinical and Administrative Advisory Committee meets 9 times per year in the Harris Service Area and quarterly in the Jefferson and Rural Service Area Northeast
• Behavioral Health Advisory Committee meets quarterly
• Perinatal Advisory Committee meets quarterly

What Does Texas Medicaid Provider Enrollment Entail

As of December 13, 2021, Medicaid enrollment for LTC providers is completed through Texas Medicaid & Healthcare Partnerships Provider Enrollment and Management System . Providers must use the new system to enroll in Texas Medicaid. The new system will be the single tool for provider enrollment, reenrollment, revalidation, and maintenance requests . For more information about the Medicaid enrollment process and PEMS Visit the TMHP website at www.tmhp.com.

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Cultural Competency And Sensitivity

Driscoll Health Plan places great emphasis on the wellness of its Members. A large part of quality health care delivery is treating the whole patient and not just the medical condition. Sensitivity to differing cultural influences, beliefs and backgrounds can improve a providers relationship with patients and in the long run the health and wellness of the patients themselves. DHP encourages all providers to be sensitive to varying cultures in the community.

For more information, please visit the Texas Health Steps website.

Texas Medicaid & Healthcare Partnership Notice

In addition to updating information with Community Health Choice, Providers must:

Update your enrollment and demographic information with TMHP . TMHP is HHSCs provider enrollment administrator and serves as the authoritative source for HHSC Providers enrollment and demographic information. Once you update your enrollment and demographic information with TMHP, your data will be reconciled with the demographic information on file with the MCOs.

To make updates to your current enrollment , please access the web page titled Provider Enrollment on the Portal A Step-by-Step Guide at the following URL:

For instructions on how to make other demographic updates to your current enrollment, please access the document titled Provider Information Management System User Guide at the following URL:

Otherwise, you can contact TMHP directly at 800-925-9126 for assistance.

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Providing A Medical Home For Clients

Providers are the crucial players in any quality health-care program. Providers enrolled with Texas Medicaid and other health-care programs render essential medical and preventive health-care services to clients while focusing on providing the best medical care possible. Texas Medicaid providers help ensure that each patient can receive high quality, comprehensive health-care services within their community.

Learn More About Texas State Health-Care Programs

Prior Authorization And Notification Resources

Demographic Information Updates with TMHP

To Providers: Please update your enrollment and demographic information with TMHP . TMHP is HHSCs provider enrollment administrator and serves as the authoritative source for HHSC Providers enrollment and demographic information. Once you update your enrollment and demographic information with TMHP, your data will be reconciled with the demographic information on file with the MCOs.

To make updates to your current enrollment , please access the web page titled Provider Enrollment and click on Enroll Today at the following URL: Provider Enrollment | TMHP.

For instructions on how to make demographic changes to your current enrollment, please access the web page titled Provider Enrollment and Management System : A Step-by-Step Guide at the following URL: Provider Enrollment and Management System | TMHP.

Otherwise, you can contact TMHP directly at 800-925-9126 for assistance.

PCP Membership Reports

The best way for primary care providers to view and export the full member roster is using the CommunityCare tool, which allows you to:

For help using CommunityCare, please see our Quick Reference Guide. If youre not familiar with our portal, go to UHCprovider.com/portal.

Reporting Fraud, Waste or Abuse to Us

Taking action and making a report is an important first step. After your report is made, we will work to detect, correct and prevent fraud, waste, and abuse in the health care system.

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What Will The Provider Screening Process Entail

Texas Medicaid providers are screened according to their risk category to fulfill requirements for enrollment as mandated by Section 6401 of the Affordable Care Act. The Center for Medicare & Medicaid Services has established 3 categories of risk: limited, moderate and high. Screening activities associated with each risk category are shown in the table below.

HHSC Contracted Community Services leverages site visits performed by HHSC Regulatory Services survey operations staff to comply with ACA site visit requirements. HHSC CCS also leverages site visits performed by TMHP contract monitoring staff. A pre-enrollment site visit is required for unlicensed entities.

How To Enroll

Go to the Enrolling in the CSHCN Services Program page of the Texas Medicaid & Healthcare Partnership website. You can enroll online or print out the paper application form to complete and return to TMHP. If you have questions, call your local area TMHP provider relations representative. To find your area representative, go to the Provider Enrollment Regional Support web page or call 800-568-2413.

Since our providers have to be enrolled in Medicaid, some of the information from your Medicaid application will be auto-populated into your online application to the Children with Special Health Care Needs Services Program, saving you time and effort.

Note: Providers of hospice and medical foods dont need to be enrolled with Medicaid.

Your online application is validated immediately, so you know that the online portion of your application is complete.

If you have questions, call your local area TMHP provider relations representative. To find your area representative, go to the Provider Enrollment Regional Support web page or call 800-568-2413.

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