Texas Medicaid Provider Enrollment Application

F00106 American LegalNet, Inc. www.FormsWorkFlow.com þ Page i þ IntroductionDear Health-Care Professional:037ank 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.037is 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 036ling procedures, 036ling deadlines, bene036ts and limitations, and much more. 037e 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 223Medicaid Provider Manual224 from the Provider home page.037ere is no guarantee your application will be approved for processing or you will be assigned a Medicaid Texas Provider Identi036er (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 StatementWith 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. 037e Health and Human Services Commission222s (HHSC) procedures for requesting corrections are in Title 1 of the Texas Administrative Code, 1 TAC 247351.17-247 351.23. 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 CorrespondenceAll correspondence related to this application (i.e., enrollment denials, de036ciency 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 InformationFor information about Medicaid provider identi036er requirements, the status of your enrollment, or claims submission, call TMHP Contact Center toll-free at 1-800-925-9126.037ank you for your applying to become a Texas Medicaid provider. American LegalNet, Inc. www.FormsWorkFlow.com þ Page ii þ Enrollment RequirementsAffordable Care ActIn compliance with the A035ordable 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:225 þ Applications for providers that are new to Texas Medicaid.225 þ Applications for providers that are requesting new practice locations.225 þ 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, Part 455, 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 ScreeningAll providers are categorized by the Centers for Medicare & Medicaid (CMS)-de036ned 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. Some provider type risk categories must be adjusted from limited or moderate to high-risk due to federal regulations. In these instances, the provider will be noti036ed of the new risk category and any associated screening requirements. Fingerprint Criminal Background Check (FCBC) All high-categorical risk level providers and their owners that have a 5 percent or more direct or indirect ownership interest must submit 036ngerprints for enrollment or revalidation in Texas Medicaid. If you have already submitted 036ngerprints for enrollment in Medicare, Texas Medicaid, or another state222s Medicaid, please submit the proof of 036ngerprinting to the address listed in the Final Checklist (page 5-1). If you have not submitted 036ngerprints for the provider and any of the 5 percent or more direct or indirect owners, please visit https://uenroll.identogo.com/servicecode/11H7TG or call 1-877-289-6114 to schedule an appointment. Once the 036ngerprinting has been completed, submit copies of the 036ngerprinting receipts for each required individual to the address listed in the Final Checklist (page 5-1). For more information about 036ngerprinting requirements or risk categories, please see the 223Texas Medicaid Provider Fingerprinting Requirement Frequently Asked Questions224 available on the TMHP website at www.tmhp.com.Provider RevalidationIn compliance with ACA, all providers are required to revalidate their enrollment at least every three to 036ve years depending on provider type. Providers will be noti036ed that they are required to revalidate before their revalidation deadline. 037e 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. Surety Bonds DME suppliers 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.Ambulance providers attempting to renew their Emergency Medical Services (EMS) license must submit a surety bond to TMHP for each license they are attempting to renew. A copy of the surety bond must also be attached to an application for renewal of an EMS license when submitted to the Department of State Health Services (DSHS).037e Surety Bond Form can be found on the TMHP website at www.tmhp.com/Pages/Medicaid/medicaidforms.aspx. American LegalNet, Inc. www.FormsWorkFlow.com þ Page iii þ Table of ContentsIntroduction þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................................................................................. iEnrollment Requirements þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................................................................................... iiTexas Medicaid Provider Enrollment Application Instructions þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................................... ivMedicare Enrollment Information þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................................................ xxvSurety Bond Information þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................................................................... xxviApplication Payment Form þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................................................................ xxviiTexas Medicaid Identi036cation For