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Texas Medicaid Provider Enrollment Application - Texas

Texas Medicaid Provider Enrollment Application Form. This is a Texas form and can be used in Medicaid Statewide .
 Fillable pdf Last Modified 10/31/2013
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Texas Medicaid Provider enrollMenT aPPlicaTion Rev. XXvI American LegalNet, Inc. www.FormsWorkFlow.com Introduction Dear Health-care Professional: Thank you for your interest in becoming a Texas Medicaid provider. Participation by providers in Texas Medicaid is vital to the successful delivery of Medicaid services, and we welcome your application for enrollment. This application must be completed in its entirety as outlined in the instructions below and will be reviewed by the Texas Health and Human Services Commission (HHSC) and the claims contractor Texas Medicaid & Healthcare Partnership (TMHP). Providers are encouraged to review the current Texas Medicaid Provider Procedures Manual for information about provider responsibilities, claims filing procedures, filing deadlines, benefits and limitations, and much more. The provider manual is updated monthly, and the current and archived provider manuals can be accessed on the TMHP web site at www.tmhp.com. Select "Reference Materials" from the Providers page. There is no guarantee your application will be approved for processing or you will be assigned a Medicaid Texas Provider Identifier (TPI) number. If you make the decision to provide services to a Medicaid client prior to approval of the application, you do so with the understanding that, if the application is denied, claims will not be payable by Texas Medicaid, and the law also prohibits you from billing the Medicaid client for services rendered. Privacy Statement With a few exceptions, Texas privacy laws and the Public Information Act entitle you to ask about the information collected on this form, to receive and review this information, and to request corrections of inaccurate information. The Health and Human Services Commission's (HHSC) procedures for requesting corrections are in Title 1 of the Texas Administrative Code, sections 351.17 through 351.23. For questions concerning this notice or to request information or corrections, please contact Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126. TMHP customer service representatives are available Monday through Friday from 7 a.m. to 7 p.m. central standard time. Application Correspondence All correspondence related to this application (i.e., enrollment denials, deficiency letters) will also be mailed to the physical address listed on your application unless otherwise requested in the Contact Information section of this application. Contact Information For information about Medicaid provider identifier requirements, the status of your enrollment, or claims submission, call TMHP Contact Center toll-free at 1-800-925-9126. Thank you for your applying to become a Texas Medicaid provider. Page i American LegalNet, Inc. www.FormsWorkFlow.com 08/27/13 Enrollment Requirements Affordable Care Act In compliance with the Affordable Care Act of 2010 (ACA), all providers are subject to ACA screening procedures for newly enrolling and re-enrolling providers. All participating providers must be screened upon submission of an application, including, but not limited to: · · · Applications for providers that are new to Texas Medicaid. Applications for providers that are requesting new practice locations. Applications for currently enrolled providers that must periodically revalidate their enrollment in Texas Medicaid. Refer to: Code of Federal Regulations (CFR) Title 42 Ch. IV, Subpart E-Provider Screening and Enrollment; and Texas Administrative Code (TAC) Title 1, Part 15, Chapter 352, for the statutory provisions for these requirements. Provider Screening All providers are categorized by the Centers for Medicare & Medicaid (CMS)-defined risk levels of limited, moderate, and high based on an assessment of potential for fraud, waste, and abuse for each provider type. Providers will be screened according to their risk level and are subject to various screening activities for each risk level. Risk level assignments may be increased at any time at the discretion of HHSC. In these instances, the provider will be notified by HHSC, and the new risk level will apply to enrollment-related transactions. Provider Revalidation In compliance with ACA, all providers are required to revalidate their enrollment at least every three to five years depending on provider type. Providers will be notified that they are required to revalidate before their revalidation deadline. The ACA screening criteria applies during revalidation. Providers that do not revalidate their enrollment by the designated date will be disenrolled and will no longer receive reimbursement from Texas Medicaid. Application Fees Under ACA, institutional providers and certain other providers are subject to an application fee for applications, including initial applications for new enrollment, applications for a new practice location, and any applications received in response to re-enrollment. Upon completion of the TMHP Provider Enrollment Application, providers will be notified whether they are required to pay an application fee. Note: The application fee is NOT required for providers that have already paid the fee to Medicare, another state's Medicaid program, or another Texas state agency. Providers will be required to provide proof of payment to TMHP. CMS sets the application fee amount, which may be adjusted annually. On rare occasions, CMS may agree to waive the application fee based on proof of financial hardship for a provider. To request a waiver, providers must submit with their enrollment application a letter that supports the request for the financial hardship waiver. The final decision to waive the application fee will be made by CMS. Surety Bonds DME suppliers and non-government-operated ambulance providers are required to submit proof of a valid surety bond when submitting: 1) an initial enrollment application to enroll in Texas Medicaid, 2) an enrollment application to establish a new practice location, 3) an enrollment application for re-enrollment in Texas Medicaid. The Surety Bond Form can be found on the TMHP website at www.tmhp.com/Pages/Medicaid/medicaid_forms.aspx. Page ii American LegalNet, Inc. www.FormsWorkFlow.com 08/27/13 Table of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i Enrollment Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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