Provider Enrollment Form Details

Medicare Provider Application Form is a necessary form to fill out in order to become a provider for Medicare. The form can be found on the official Medicare website and must be filled out accurately in order to ensure a smooth process. The form covers basic information about the provider, such as name and address, as well as more specific information about the services they offer. Completing the form correctly is important in order to avoid any delays in getting started with providing services to Medicare beneficiaries.

In the table, there's some information relating to the medicare provider application. It may be helpful to know its size, the actual time required to prepare the form, the fields you should fill in, and so forth.

QuestionAnswer
Form NameMedicare Provider Application
Form Length81 pages
Fillable?No
Fillable fields0
Avg. time to fill out20 min 15 sec
Other namesmust application providers, provider enrollment application, medicare provider application, texas medicare application

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TEXAS MEDICAID

PROVIDER ENROLLMENT

APPLICATION

REV. XXXVI

F00106

INTRODUCTION

Dear Health-Care Professional:

hank 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.

his 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 iling procedures, iling deadlines, beneits and limitations, and much more. he 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 “Medicaid Provider Manual” from the Provider home page.

here is no guarantee your application will be approved for processing or you will be assigned a Medicaid Texas Provider Identiier (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. he Health and Human Services Commission’s (HHSC) procedures for requesting corrections are in Title 1 of the Texas Administrative Code, 1 TAC §351.17-§ 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, deiciency 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 identiier requirements, the status of your enrollment, or claims submission, call TMHP Contact Center toll-free at 1-800-925-9126.

hank you for your applying to become a Texas Medicaid provider.

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ENROLLMENT REQUIREMENTS

AFFORDABLE CARE ACT

In compliance with the Afordable 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, 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 SCREENING

All providers are categorized by the Centers for Medicare & Medicaid (CMS)-deined 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 notiied 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 ingerprints for enrollment or revalidation in Texas Medicaid. If you have already submitted ingerprints for enrollment in Medicare, Texas Medicaid, or another state’s Medicaid, please submit the proof of ingerprinting to the address listed in the Final Checklist (page 5-1).

If you have not submitted ingerprints 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 ingerprinting has been completed, submit copies of the ingerprinting receipts for each required individual to the address listed in the Final Checklist (page 5-1). For more information about ingerprinting requirements or risk categories, please see the “Texas Medicaid Provider Fingerprinting Requirement Frequently Asked Questions” available on the TMHP website at www.tmhp.com.

PROVIDER REVALIDATION

In compliance with ACA, all providers are required to revalidate their enrollment at least every three to ive years depending on provider type. Providers will be notiied that they are required to revalidate before their revalidation deadline. he 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).

he Surety Bond Form can be found on the TMHP website at www.tmhp.com/Pages/Medicaid/medicaid_forms.aspx.

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TABLE OF CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i Enrollment Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii Texas Medicaid Provider Enrollment Application Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Medicare Enrollment Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv Surety Bond Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xxvi Application Payment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii Texas Medicaid Identiication Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1 Texas Medicaid Provider Enrollment Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-1

Section A: Provider of Service Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-1

A.2 Provider Specialty/Taxonomy Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-2

A.3 Provider Demographic Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-3

A.4 Children’s Health Insurance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-3

A.5 Healthy Texas Women (HTW) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-3

Section B: Disclosure of Ownership and Control Interest Statement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-4 B.1 Disclosure of Ownership Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-4 B.2 Disclosure of Ownership Form (3 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-5 B.3 Principal Information Form (PIF-2) (6 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-8 Section C: Group Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-14 Section D: Provider Information Form (PIF-1) (6 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-15

HHSC Medicaid Provider Agreement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-1 IRS W–9 Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-1 Final Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-1 Appendix A: Additional Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1 Corporate Board of Directors Resolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-2 Medicaid Audit Information Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-3 Physician’s Letter of Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-4 Electronic Funds Transfer (EFT) Notiication (5 pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-5 Healthy Texas Women Certiication (3 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-10 Appendix B: Useful Information - Please Read . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1

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TEXAS MEDICAID PROVIDER ENROLLMENT APPLICATION INSTRUCTIONS

ALL PROVIDERS

his Texas Medicaid Provider Enrollment Application can be completed to enroll in Texas Medicaid as a traditional Medicaid provider, a Texas Health Steps (THSteps) medical check-up provider, and a Children with Special Health Care Needs (CSHCN) Services Program provider. Upon completion of this application, qualiied providers will automatically be enrolled as THSteps medical check-up providers and CSHCN Services Program providers unless they choose to opt out of one or both as prompted in this application.

If the provider chooses to opt out of THSteps or the CSHCN Services Program upon submission of this application, the following applications are available on the TMHP website at www.tmhp.com and can be submitted at a later time to enroll:

THSteps Provider Enrollment Application

CSHCN Services Program Provider Enrollment Application

he following applications are available on the TMHP website at www.tmhp.com for enrollment in other Texas Medicaid programs:

Texas Medicaid Provider Enrollment Application Ordering and Referring Providers Only

THSteps Dental Provider Enrollment Application

Medical Transportation Program (MTP) Provider Enrollment Application

Texas Vaccines for Children Program (TVFC)

To complete this Texas Medicaid Provider Enrollment Application, the following forms must be completed and returned for processing:

Application Payment Form (if applicable) (refer to the instructions for additional information) (page xxvii)

Medicare Enrollment Information Form (page xxv)

Texas Medicaid Identiication Form (page 1-1 through 1-3)

Texas Medicaid Provider Enrollment Application (page 2-1 through 2-3)

Disclosure of Ownership and Control Interest Statement Form (performing providers and SHARS providers are exempt) (page 2-5 through 2-7)

Principal Information Form (PIF-2) (performing providers are exempt) (page 2-8 through 2-13)

Provider Information Form (PIF-1) (page 2-15 through 2-20)

HHSC Medicaid Provider Agreement (original signatures required) (page 3-1 through 3-7)

IRS W-9 Form (performing providers exempt) (page 4-1 through 4-4)

PROVIDERS INCORPORATED IN TEXAS

If the enrolling provider is incorporated in Texas, the following additional forms must be submitted:

Corporate Board of Directors Resolution Form. his document must contain original signatures and be notarized.

Articles or Certiication of Incorporation or Certiicate of Fact. If a corporation was formed before 2006, one of these certiicates must be obtained from the Oice of the Secretary of State.

Certiicate of Formation or Certiicate of Filing. If a corporation was formed ater 2006, one of these certiicates must be obtained from the Oice of the Secretary of State.

Franchise Tax Account Status. Refer to the “Additional Instructions — Appendix A” for further information.

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OUT-OF-STATE INCORPORATED PROVIDERS

If the enrolling provider is incorporated in another state, the following additional forms must be submitted:

Corporate Board of Directors Resolution Form. his document must contain original signatures and be notarized.

Certiication of Registration or Certiicate of Authority. One of these certiicates must be obtained from the Oice of the Secretary of State.

Franchise Tax Account Status Page. Refer to the “Additional Instructions — Appendix A” for further information.

ADDITIONAL DOCUMENTATION REQUIRED FOR SPECIC PROVIDER TYPES

he following attachments must be submitted with the enrollment application if applicable for the requested provider type:

Copy of Certiication of Mammography Systems from the Bureau of Radiation Control (BRC) (for all providers rendering mammography services)

Copy of CLIA Certiicate with approved specialty services as appropriate

Medicaid Audit Information Form (facilities only)

Healthy Texas Women Certiication (original signatures required)

Important: Retain a copy for your records of all documents submitted for enrollment.

ADDITIONAL ENROLLMENT CRITERIA FOR OUT-OF-STATE PROVIDERS

Out-of-state providers are subject to a limited enrollment term. You must submit proof of meeting one of the following criteria prior to being able to enroll with Texas Medicaid:

A medical emergency documented by the attending physician or other provider.

he client’s health is in danger if he or she is required to travel to Texas.

Services are more readily available in the state where the client is temporarily located.

he customary or general practice for clients in a particular locality is to use medical resources in the other state (this is limited to providers located in a state bordering Texas).

All services provided to adopted children receiving adoption subsidies (these children are covered for all services, not just emergency).

he services are medically necessary and the nature of the service is such that providers for this service are limited or not readily available within the state of Texas.

he services are medically necessary services to one or more dually eligible recipients (i.e., recipients who are enrolled in both Medicare and Medicaid)

he services are provided by a pharmacy that is a distributor of a drug that is classiied by the U.S. Food and Drug Administration (FDA) as a limited distribution drug.

he services are medically necessary and one or more of the following exceptions for good cause exist and can be documented:

Texas Medicaid enrolled providers rely on the services provided by the applicant.

Applicant maintains existing agreements as a participating provider through one or more Medicaid managed care organizations (MCO) and enrollment of the applicant leads to more cost-efective delivery of Medicaid services.

A laboratory may participate as an in-state provider, regardless of the location where any speciic service is performed or where the laboratory’s facilities are located if:

he laboratory or an entity that is a parent, subsidiary, or other ailiate of the laboratory maintains laboratory operations in Texas;

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he laboratory and each entity that is a parent, subsidiary, or other ailiate of the laboratory, individually or collectively, employ at least 1,000 persons at places of employment located in this state; and

he laboratory is otherwise qualiied to provide the services under the program and is not prohibited from participating as a provider under any beneit programs administered by a health and human services agency, including HHSC, based on conduct that constitutes fraud, waste, or abuse.

Refer to: he current Texas Medicaid Provider Procedures Manual at www.tmhp.com for further information.

INSTRUCTIONS FOR COMPLETING THE APPLICATION AND ADDITIONAL FORMS

Complete the Texas Medicaid Provider Enrollment Application using the following information:

Item

Instructions

Application

Certain providers are required to submit the application fee. his application cannot be

Payment Form

processed if the application fee is required and is not submitted with the application. For more

 

information, refer to “Provider Types Required to Pay an Application Fee” available on the

 

TMHP website at www.tmhp.com.

Medicare

REQUIRED: Medicare enrollment is a prerequisite for Medicaid enrollment if you render

Enrollment

services for clients who are eligible for Medicare. If you have a Medicare number that pertains

Information

to this enrollment, you must supply the number to TMHP. If you do not have a Medicare

 

number and are eligible for a Medicare Waiver Request, check the box for the waiver request

 

that matches your situation (see page xxv).

 

his information is required. Your enrollment in Texas Medicaid may be delayed if this

 

section of the application is not completed at the time of submission.

Type of

Choose the appropriate box to indicate if this is a new enrollment for a new provider, new

Enrollment:

provider type, new practice location, etc. or if this enrollment is in response to a

 

re-enrollment letter.

Requesting

Choose one as deined below:

Enrollment as:

Individual enrollment. his type of enrollment applies to an individual health-care

 

 

professional who is licensed or certiied in Texas, and who is seeking enrollment under the

 

name, and social security or tax identiication number of the individual. An individual may

 

also enroll as an employee, using the tax identiication number of the employer. Certain

 

provider types must enroll as individuals, including dieticians, licensed vocational nurses

 

(LVN), occupational therapists, and speech therapists.

 

Group enrollment. his type of enrollment applies to health-care items or services provided

 

under the auspices of a legal entity, such as a partnership, corporation, limited liability

 

company, or professional association, and the individuals providing health-care items or

 

services are required to be certiied or licensed in Texas. he enrollment is under the name and

 

tax identiication number of the legal entity. For any group enrollment application, there must

 

also be at least one enrolling performing provider.

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Item

Instructions

Requesting

Performing Provider enrollment. his type of enrollment applies to an individual health-care

Enrollment as:

professional who is licensed or certiied in Texas, and who is seeking enrollment under a group.

(cont.)

he enrollment is under the tax identiication 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 tax identiication number of their employer.

 

Facility enrollment. his type of enrollment applies to situations in which licensure or

 

certiication applies to the entity. Although individuals working for or with the entity may be

 

licensed or certiied in their individual capacity, the enrollment is based on the licensure or

 

certiication of the entity. For this reason, facility enrollment does not require enrollment of

 

performing providers.

List NPI

Enter your National Provider Identiier (NPI) in this box. An NPI is not required for Financial

 

Management Services Agency (FMSA), Milk Donor Bank, Personal Assistance Services, and

 

Service Responsibility Option (SRO) providers.

Additional

Upon completion of this application, you will automatically be enrolled in the CSHCN Services

Enrollment

Program unless you opt out of CSHCN Services Program enrollment. Check the box if you

 

are opting out of CSHCN Services Program enrollment. If you check this box, you will only be

 

considered for enrollment in Texas Medicaid.

 

Note: If you do not check this box indicating that you would like to be considered for enrollment

 

in the CSHCN Services Program, also complete the following forms that are available for

 

download at www.tmhp.com:

 

CSHCN Services Program Identiication Form

 

Provider Agreement with the Department of State Health Services (DSHS) for

 

Participation in the Children with Special Health Care Needs (CSHCN) Services

 

Program

 

Required Information for Customized Durable Medical Equipment (DME) Providers

 

(as applicable)

 

Required Information for Enrollment as a CSHCN Services Program Dental

 

Orthodontia Provider (as applicable)

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Item

Instructions

Texas Medicaid Identiication Form – Traditional Services

Texas Medicaid services are categorized by traditional services, case management services, and Comprehensive Care Program (CCP) services. Check the box with the appropriate category that identiies the provider type with which you are seeking enrollment. Check only the appropriate box to ensure proper enrollment. For assistance in choosing the appropriate provider type, please refer to the instructions.

Traditional

Anesthesiologist Assistant (AA). To enroll in Texas Medicaid, AAs must be certiied by the

Services

National Commission for Certiication of Anesthesiologist Assistants. AA providers must

 

enroll as performing providers into an anesthesiology group or a clinic/group practice. If

 

enrolling into a Medicare enrolled clinic/group practice, Medicare enrollment is required.

 

Certiication information will be required upon enrollment.

Traditional

Ambulance/ Air Ambulance. To enroll in Texas Medicaid, ambulance providers must: 1)

Services

operate according to the laws, regulations, and guidelines governing ambulance services under

 

Medicare Part B; 2) equip and operate under the appropriate rules, licensing, and regulations

 

of the state in which they operate; 3) acquire a license from Texas Department of State Health

 

Services (DSHS) approving equipment and training levels of the crew; 4) enroll in Medicare. A

 

hospital-operated ambulance provider must be enrolled as an ambulance provider and submit

 

claims using the ambulance TPI, not the hospital TPI.

 

You must attach a copy of your permit/license.

 

In addition, ambulance providers must disclose the Medical Director (a physician who is

 

actively licensed by the Texas Medical Board). A PIF-2 will be required of the Medical Director.

 

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).

Traditional

Ambulatory Surgical Center (ASC). To enroll in Texas Medicaid, ASCs must: meet and

Services

comply with applicable state and federal laws and provisions of the state plan under Title XIX

 

of the Social Security Act for Medical Assistance, and be enrolled in Medicare. Out-of-state

 

ASCs that are Medicare-certiied as an ASC in the state where they are located and provide

 

services to a Texas Medicaid client may be entitled to participate in Texas Medicaid.

Traditional

Audiologist. To enroll in Texas Medicaid, audiologists who provide hearing evaluations or

Services

itting and dispensing services must:

 

Be licensed by the licensing board of their profession to practice in the state where the

 

services are performed at the time the services are provided.

 

Be enrolled as a Medicare provider.

 

Be currently certiied by the American Speech, Language, and Hearing Association or

 

meet the Association’s equivalency requirements.

 

Audiologists can enroll as an individual, group, or as a performing provider in a clinic/group

 

practice.

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Item

Instructions

 

Traditional

Birthing Center. To enroll in Texas Medicaid, a birthing center must be licensed by DSHS.

Services

Texas Medicaid only reimburses birthing center services that provide a level of service equal to

 

the professional skills of a physician, certiied nurse-midwife (CNM), or licensed midwife (LM)

 

who acts as the birth attendant. A birthing center is deined as a facility or institution where a

 

woman is scheduled to give birth following an uncomplicated (low-risk) pregnancy. his term

 

does not include a hospital, ambulatory surgical center, nursing facility, or residence of the

 

woman giving birth.

 

 

You must attach a copy of your license.

 

Traditional

Catheterization Lab. To enroll in Texas Medicaid, a catheterization lab must be Medicare-

Services

certiied.

 

Traditional

Certiied Registered Nurse Anesthetist (CRNA). To enroll in Texas Medicaid, a CRNA

Services

must be a registered nurse approved as an advanced practice nurse by the state in which they

 

practice and be currently certiied by either the Council on Certiication of Nurse Anesthetists

 

or the Council on Recertiication of Nurse Anesthetists. Medicare enrollment is a prerequisite

 

for enrollment as a Medicaid provider. CRNAs can enroll as an individual, group or as a

 

performing provider into a clinic/group practice. If enrolling into a Medicare enrolled clinic/

 

group practice, Medicare enrollment is required.

 

 

You must attach a copy of your CRNA certiication or re–certiication card.

Traditional

Certiied Nurse Midwife (CNM). To enroll in Texas Medicaid, a CNM must be a licensed

Services

registered nurse who is recognized by the Texas Board of Nursing as an advanced practice

 

nurse in nurse-midwifery and certiied by the American College of Nurse-Midwives. Medicare

 

enrollment is a prerequisite for enrollment as a Medicaid provider.

 

CNMs must complete the Physician Letter of Agreement form for Certiied Nurse Midwife

 

(CNM) and Licensed Midwife (LM) Providers and submit the agreement with this enrollment

 

application.

 

Traditional

Chemical Dependency Treatment Facility. Chemical dependency treatment facilities licensed

Services

by DSHS are eligible to enroll in Texas Medicaid. Chemical dependency treatment facility

 

services are those facility services determined by a qualiied credentialed professional, as

 

deined by the DSHS Chemical Dependency Treatment Facility Licensure Standards, to be

 

reasonable and necessary for the care of clients of any age.

 

 

You must attach a copy of your license.

 

Traditional

Chiropractor. To enroll in Texas Medicaid, a doctor of chiropractic (DC) medicine must

Services

be licensed by the Texas Board of Chiropractic Examiners and enrolled as a Medicare

 

provider. Chiropractors can enroll as an individual, group or as a performing provider into

 

a clinic/group practice. If enrolling into a Medicare enrolled clinic/group practice, Medicare

 

enrollment is required.

 

Traditional

Clinic/Group Practice. Physicians and behavioral health providers can enroll in Texas

Services

Medicaid as a clinic/group practice. All providers enrolled in the clinic/group practice must

 

be actively enrolled in Medicare and must enroll in Texas Medicaid as part of the clinic/group

 

practice. All providers must be licensed as Physicians by the Texas Medical Board or by the

 

appropriate state board where services are rendered.

 

Traditional

Community Mental Health Center – To enroll in Texas Medicaid, the provider must be

Services

actively enrolled in Medicare.

 

 

 

 

 

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Traditional

Comprehensive Health Center (CHC). To enroll in Texas Medicaid to provide medical

Services

services, physicians (MD and DO) and doctors (DMD, DDS, OD, DPM, and DC) must be

 

licensed by the licensing authority of their profession to practice in the state where the service is

 

performed at the time services are provided. All physicians except pediatricians and physicians

 

doing only THSteps medical screens must be enrolled in Medicare before Medicaid enrollment.

 

Providers must submit a Medicare Waiver Request if their type of practice and service may

 

never be billed to Medicare.

Traditional

Comprehensive Outpatient Rehab Facility (CORF). To enroll in Texas Medicaid, a CORF

Services

must be Medicare-certiied. CORFs are public or private institutions primarily engaged

 

in providing, under medical direction, diagnostic, therapeutic, and restorative services to

 

outpatients, and are required to meet speciied conditions of participation.

Traditional

Dentist/Doctor of Dentistry as a Limited Physician. Dentists can enroll as traditional

Services

Medicaid providers to be reimbursed for medically necessary dental services, and as THSteps

 

dental providers to be reimbursed for preventive dental care for THSteps dental clients.

 

To enroll as a Doctor of Dentistry Practicing as a Limited Physician, a dentist must be currently

 

licensed by the TSBDE or currently be licensed in the state where the service was performed

 

at that time, have a Medicare provider identiication number before applying for and receiving

 

a Medicaid provider identiier and enroll as a Medicaid provider with a limited physician

 

provider identiier using the Traditional Medicaid Provider Enrollment Application.

 

Dentists must complete an enrollment application for each separate practice location and will

 

receive a unique nine-digit Medicaid provider identiication number for each practice location.

 

Dentists can enroll as individuals, dentist groups, or performing providers into a clinic/group

 

practice. he owner of the group must be a licensed dentist.

 

Note: he Texas Medicaid Provider Enrollment Application is required to enroll in Texas

 

Medicaid as a Doctor of Dentistry as a Limited Physician. To enroll in Texas Medicaid as a

 

THSteps dental provider, complete and submit the Texas Health Steps (THSteps) Dental Provider

 

Enrollment Application.

Traditional

Durable Medical Equipment (DME). A provider supplying medical equipment or appliances

Services

that are manufactured to withstand repeated use, ordered by a physician for use in the home,

 

and required to correct or ameliorate a client’s disability, condition, or illness. hese providers

 

must be Medicare-certiied as a DME/medical supplier. Providers of customized, non-basic

 

medical equipment, expendable medical supplies, and orthotic or prosthetic devices are also

 

enrolled as a DME provider. Prescriptions, insulin, and insulin syringes are covered through

 

the Medicaid Vendor Drug Program. Refer to the Pharmacy section for more information on

 

pharmacies enrolled as Comprehensive Care Program (CCP) providers.

 

DME providers must purchase a surety bond as a condition of enrollment in Texas Medicaid.

 

he State of Texas Medicaid Provider Surety Bond Form must be submitted with this

 

application.

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Traditional

Family Planning Agency. Family planning services are preventive health, medical,

Services

counseling, and educational services that assist individuals in managing their fertility and

 

achieving optimal reproductive and general health. To enroll in Texas Medicaid, family

 

planning agencies must ensure that all services are furnished by, prescribed by, or provided

 

under the direction of a licensed physician and have a medical director who is a physician

 

currently licensed to practice medicine in Texas. Agencies must have an established record of

 

performance in the provision of both medical and educational/counseling family planning

 

services as veriied through client records, established clinic hours, and clinic site locations;

 

provide family planning services in accordance with DSHS standards of client care for family

 

planning agencies; and be approved for family planning services by the DSHS Family Planning

 

Program. Physicians who wish to provide Medicaid Obstetric and Gynecologic (OB-GYN)

 

services are allowed to bypass Medicare enrollment and obtain a Medicaid-only TPI for

 

OB-GYN services regardless of provider specialty. Similarly, federally qualiied health centers

 

do not need to apply for a separate physician or agency number. Family planning services are

 

payable under the existing FQHC TPI using family planning procedure codes.

Traditional

Federally Qualiied Health Center/Federally Qualiied Satellite/Federally Qualiied Look-

Services

Alike. To enroll in Texas Medicaid, a Federally Qualiied Health Center (FQHC) must be

 

receiving a grant under Section 329, 330, or 340 of the Public Health Service Act or designated

 

by the U.S. Department of Health and Human Services to have met the requirements to

 

receive this grant. FQHCs and their satellites are required to enroll in Medicare to be eligible

 

for Medicaid enrollment. FQHC “look-alikes” are not required to enroll in Medicare but may

 

elect to do so to receive reimbursement for crossovers. A copy of the Public Health Service

 

issued notice of grant award relecting the project period and the current budget period

 

must be submitted with the enrollment application. A current notice of grant award must be

 

submitted to the TMHP Provider Enrollment Department annually. Centers are required to

 

notify TMHP of all satellite centers that are ailiated with the parent FQHC and their actual

 

physical addresses. All FQHC satellite centers billing Medicaid for FQHC services must also

 

be approved by the Public Health Service. For accounting purposes, centers may elect to enroll

 

the Public Health Service–approved satellites using an Federally Qualiied Satellite (FQS)

 

TPI that ties back to the parent FQHC TPI and Federal Tax ID. his procedure allows for the

 

parent FQHC to have one provider agreement as well as one cost report combining all costs

 

from all approved satellites and the parent FQHC. If an approved satellite chooses to bill Texas

 

Medicaid directly, the center must have a separate TPI from the parent FQHC and will be

 

required to ile a separate cost report.

 

 

You must attach a copy of your grant award and the Federally Qualiied Health Center

 

Ailiation Aidavit. he form may be downloaded from the TMHP website at

 

www.tmhp.com.

 

Traditional

Freestanding Psychiatric Facility. To be eligible to participate in CCP, a psychiatric hospital/

Services

facility must be accredited by the Joint Commission, have a valid provider agreement with

 

HHSC, and have completed the TMHP enrollment process. Facilities certiied by Medicare

 

must also meet the Joint Commission accreditation requirements. Freestanding psychiatric

 

hospitals enrolled in Medicare may also receive payment for Medicare deductible and

 

coinsurance amounts with the exception of clients ages 21-64.

Traditional

Freestanding Rehabilitation Facility. To be eligible to participate in CCP, a freestanding

Services

rehabilitation hospital must be certiied by Medicare, have a valid Provider Agreement with

 

HHSC, and have completed the TMHP enrollment process. Texas Medicaid enrolls and

 

reimburses freestanding rehabilitation hospitals for CCP services and Medicare deductible/

 

coinsurance. he information in this section is applicable to CCP services only.

 

 

 

 

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Instructions

Traditional

Genetics. Only full-service genetic providers may enroll in Texas Medicaid. Before enrolling,

Services

the provider must contract with DSHS for the provision of genetic services. Basic contract

 

requirements are as follows. 1) he provider’s medical director must be a clinical geneticist

 

(MD or DO) who is board eligible/certiied by the American Board of Medical Geneticists

 

(ABMG). he physician must oversee the delivery and content of all medical services. 2)

 

he provider must use a team of professionals to provide genetic evaluative, diagnostic, and

 

counseling services. he team rendering the services must consist of at least the following

 

professional staf. 3) he clinical geneticist (MD or DO) and at least one of the following:

 

nurse, genetic associate, social worker, medical geneticist, or genetic counselor. Administrative

 

personnel and support staf may also be involved. Additionally, each genetic professional

 

providing clinical services must obtain a performing TPI from TMHP. For more contracting

 

information, contact: DSHS Genetic Screening and Case Management Division, 1100 West

 

49th Street, Austin TX 78756-3199, 512-458-7111 X2193.

Traditional

HCSSA. Home and Community Support Services Agency (HCSSA). An entity licensed

Services

by DADS that provides home care, hospice, or personal assistance services for pay or

 

other consideration in a client’s residence, an independent living environment, or another

 

appropriate location.

 

Refer to the Home Health section of this instruction table for additional information about

 

HCSSA enrollment for home health agencies.

Traditional

Hearing Aid. To enroll in Texas Medicaid, hearing aid itters and dispensers must be licensed

Services

by the licensing board of their profession to practice in the state where the services are

 

performed at the time the services are provided. Audiologists and physicians who provide

 

itting and dispensing services should choose their respective provider type.

Traditional

Home Health. Home health services (e.g., intermittent skilled nursing, physical therapy,

Services

occupational therapy and home health aide) are provided under Texas Medicaid as Title XIX

 

services. To enroll, a provider must be a licensed HCSSA that is also Medicare certiied. hese

 

facilities will have the Licensed and Certiied Home Health (LCHH) category listed on the

 

DADS issued license. Home health providers may render traditional Title XIX Medicaid home

 

health services, telemonitoring services, and CCP services.

 

Licensed Home Health-CCP. Licensed Home and Community Support Services Agencies

 

(HCSSA) that are not Medicare certiied, but have the licensed home health category on their

 

DADS issued license may provide only Private Duty Nursing, CCP therapy to children (0-20),

 

telemonitoring services, or Personal Care Services (PCS) under Texas Medicaid Comprehensive

 

Care Program. HCSSAs that also wish to provide Title XIX, Medicaid home health services

 

must also be Medicare certiied.

 

Note: Home health providers with a category of service of hospice are not enrolled in Texas

 

Medicaid.

Traditional

Hospital – In State. To be eligible to participate in Texas Medicaid, a hospital must be certiied

Services

by Medicare, have a valid provider agreement with HHSC, and have completed the TMHP

 

enrollment process.

Traditional

Hospital Ambulatory Surgical Center (HASC). Hospitals certiied and enrolled in Texas

Services

Medicaid are assigned a nine-character TPI (HASC) exclusively for billing day surgeries.

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Traditional

Hospital – Military. To enroll in Texas Medicaid, a military hospital must be certiied by

Services

Medicare, have a valid provider agreement with HHSC, and have completed the TMHP

 

enrollment process. Veteran’s Administration (VA) hospitals are eligible to receive Texas

 

Medicaid payment only on claims that have crossed over from Medicare.

Traditional

Hospital – Out of State. To be eligible to participate in Texas Medicaid, a hospital must be

Services

certiied by Medicare, have a valid provider agreement with HHSC, and have completed the

 

TMHP enrollment process.

Traditional

Hyperalimentation. To enroll in Texas Medicaid, providers of in-home total parental

Services

parenteral nutrition must be enrolled in Medicare (Palmetto) as in-home total parental

 

hyperalimentation supplier providers.

Traditional

Independent Diagnostic Testing Facility (IDTF). To enroll in Texas Medicaid, an IDTF

Services

provider must be actively enrolled in Medicare.

Traditional

Independent Laboratory (No Physician involvement/Physician involvement). To enroll

Services

in Texas Medicaid, the independent (freestanding) laboratory must: 1) be independent from

 

a physician’s oice or hospital; 2) meet staf, equipment, and testing capability standards for

 

certiication by HHSC; and 3) have Medicare certiication.

Traditional

Licensed Marriage Family herapist (LMFT). To enroll in the Texas Medicaid Program,

Services

whether as an individual or as part of a group, a licensed marriage and family therapist

 

(LMFT) must be licensed by the Texas State Board of Examiners of Licensed Marriage and

 

Family herapists. LMFTs are covered as Medicaid-only providers. herefore, enrollment in

 

Medicare is not a requirement. LMFTs can enroll as part of a clinic/group practice whether or

 

not they are enrolled in Medicare. Providers that hold a temporary license are not eligible to

 

enroll in the Texas Medicaid Program.

Traditional

Licensed Midwife (LM). To enroll in Texas Medicaid, an LM must be licensed and approved

Services

by the Texas Midwifery Board under Chapter 203 of the Occupations Code and 22 TAC

 

Chapter 831 (relating to Midwifery). Per the Afordable Care Act, Section 2301, LMs are able

 

to perform certain professional services in birthing centers, given they are licensed birthing

 

attendants as recognized by Texas. LMs are required to retain a referring/consulting physician

 

as a condition of enrollment. LMs can enroll as an individual, group, or performing provider

 

into a clinic/group practice. LMs are not recognized by Medicare and are not required to enroll

 

in Medicare as a prerequisite for Medicaid enrollment.

 

LMs must complete the Physician Letter of Agreement form for Certiied Nurse Midwife

 

(CNM) and Licensed Midwife (LM) Providers and submit the agreement with this enrollment

 

application.

Traditional

Licensed Professional Counselor (LPC). To enroll in the Texas Medicaid Program,

Services

independently or as a group of practicing licensed professional counselors (LPCs), you must

 

be licensed by the Texas State Board of Examiners of Professional Counselors. LPCs are

 

covered as Medicaid-only providers; therefore, enrollment in Medicare is not a requirement

 

for enrollment in Medicaid. Practitioners holding a temporary license are not eligible to enroll

 

in Medicaid. LPCs can enroll as an individual, group or as a performing provider into a clinic/

 

group practice. he Provider Agreement, Provider Information Form (PIF-1) and, Principal

 

Information Form (PIF-2) must be complete for the group and each performing provider

 

enrolling into the group.

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Traditional

Maternity Service Clinic (MSC). To enroll in Texas Medicaid, maternity service clinics (MSC)

Services

must ensure that the physician prescribing the services is employed by or has a contractual

 

agreement/formal arrangement with the clinic to assume professional responsibility for the

 

services provided to clinic patients. To meet this requirement a physician must see the patient

 

at least once, prescribe the type of care provided, and if the services are not limited by the

 

prescription, periodically review the need for continued care. Medicare certiication is not a

 

prerequisite for MSC enrollment. An MSC must: 1) be a facility that is not an administrative,

 

organizational, or inancial part of a hospital; 2) be organized and operated to provide

 

maternity services to outpatients; 3) comply with all applicable federal, state, and local laws

 

and regulations; 4) an MSC wanting to bill and receive reimbursement for case management

 

services to high-risk pregnant adolescents, women, and infants must meet the criteria speciied

 

in the Case Management for Children and Pregnant Women section.

Traditional

Nurse Practitioner/Clinical Nurse Specialist (NP/CNS). To enroll in Texas Medicaid, a Nurse

Services

Practitioner (NP), or Clinical Nurse Specialist (CNS) must be licensed as a registered nurse and

 

recognized as an Advanced Practice Registered Nurse (APRN) by the Texas Board of Nursing

 

(TBON). An NP or a CNS can enroll as an individual provider, or a performing provider of a

 

clinic/group practice. If an NP or a CNS is enrolling as a performing provider in a Medicare-

 

enrolled clinic/group practice, the NP or CNS must also be enrolled in Medicare. Providers

 

must submit a Medicare Waiver Request if their type of practice and service may never be

 

billed to Medicare. Under the multi-state licensure compact, an APRN may be licensed in

 

another state but must also be certiied as an APRN by the TBON.

Traditional

Occupational herapist (OT). To enroll in Texas Medicaid, the provider must be licensed

Services

as an Occupational herapist by the Executive Council of Physical herapy & Occupational

 

herapy Examiners or by the appropriate state board where services are rendered. he provider

 

must be actively enrolled in Medicare as an occupational therapist.

 

Occupational therapists are also eligible to enroll in CCP. Refer to the Occupational herapist-

 

CCP section of this instructions table for additional information.

Traditional

Optician. To enroll in the Texas Medicaid Program, doctors of optometry must be licensed by

Services

the licensing board of their profession to practice in the state where the service was performed,

 

at the time the service was performed, and be enrolled as Medicare Providers. Opticians

 

can enroll as an individual, group or as a performing provider into a clinic/group practice. If

 

enrolling into a Medicare enrolled clinic/group practice, Medicare enrollment is required..

Traditional

Optometrist (OD). To enroll in the Texas Medicaid Program, doctors of optometry must be

Services

licensed by the licensing board of their profession to practice in the state where the service

 

was performed, at the time the service was performed, and be enrolled as Medicare Providers.

 

Optometrists can enroll as an individual, group or as a performing provider into a clinic/group

 

practice. If enrolling into a Medicare enrolled clinic/group practice, Medicare enrollment is

 

required.

Traditional

Orthotist. Orthotists must be enrolled in Medicare and licensed by the Texas Board of

Services

Orthotics and Prosthetics as a licensed orthotist (LO) or licensed prosthetist/orthotist (LPO)

 

to measure, design, fabricate, assemble, it, adjust, or service an orthosis for the correction or

 

alleviation of a neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.

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Traditional

Outpatient Rehabilitation Facility (ORF). To enroll in Texas Medicaid, an ORF must be

Services

Medicare-certiied. ORFs are public or private institutions primarily engaged in providing,

 

under medical direction, diagnostic, therapeutic, and restorative services to outpatients, and

 

are required to meet speciied conditions of participation.

Traditional

Personal Assistant Services/PCS. Providers that want to participate in the delivery of PCS

Services

must have one of the following Texas Department of Aging and Disability Services (DADS)

 

licensures:

 

Personal assistance services (PAS)

 

Licensed home health services (LHHS)

 

Licensed and certiied home health services (LCHHS)

 

Licensed Home and Community Support Services Agencies (HCSSA) that are not Medicare

 

certiied may provide ONLY Personal Care Services (PCS) under Texas Medicaid CCP.

Traditional

Pharmacy Group. A pharmacy is a facility used by pharmacists for the compounding and

Services

dispensing of medicinal preparations and other associated professional and administrative

 

services. A pharmacy is a facility whose primary function is to store, prepare and legally

 

dispense prescription drugs under the professional supervision of a licensed pharmacist. It

 

meets any licensing or certiication standards set forth by the jurisdiction where it is located.

 

Pharmacies must complete an application as a “group” if interested in providing Medicaid

 

clients only vaccines. As a “group” applicant, at least one performing provider application

 

must be submitted as a pharmacist. Pharmacies must be certiied by Medicare. Pharmacies

 

must complete the application as a “facility” if interested in providing DME and supplies to all

 

Medicaid clients. Each pharmacy must be certiied by Medicare.

Traditional

Pharmacist. A pharmacist is an individual licensed by the appropriate state regulatory

Services

agency to engage in the practice of pharmacy. he practice of pharmacy includes, but is not

 

limited to: assessment, interpretation, evaluation and implementation, initiation, monitoring

 

or modiication of medication and or medical orders; the compounding or dispensing of

 

medication and or medical orders; participation in drug and device procurement, storage,

 

and selection; drug administration; drug regimen reviews; drug or drug-related research;

 

provision of patient education and the provision of those acts or services necessary to provide

 

medication therapy management services in all areas of patient care. Pharmacists must

 

complete an application as an “individual” or “performing provider” under a pharmacy

 

“group” if interested in providing Medicaid clients only vaccines. Pharmacists must be certiied

 

by Medicare and certiied to perform immunizations.

Traditional

Physical herapist (PT). To enroll in Texas Medicaid, independently practicing licensed

Services

physical therapists must be enrolled in Medicare. If you are currently enrolled with Texas

 

Medicaid or plan to provide regular acute care services to clients with Medicaid coverage,

 

enrollment in CCP is not necessary. All non-CCP physical therapy services must be billed with

 

your current Medicaid TPI.

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Traditional

Physician. To enroll in Texas Medicaid in order to provide medical services, physicians (M.D.

Services

and D.O.) must:

 

Be licensed by the licensing authority of their profession to practice in the state where the

 

services are performed at the time the services are provided.

 

Be enrolled as a Medicare provider with the exception of pediatricians and obstetrics and

 

gynecology (OB-GYN) providers

 

Submit a Medicare Waiver Request if their type of practice and service may never be billed

 

to Medicare.

 

If enrolling into a Medicare enrolled clinic/group practice, Medicare enrollment is required.

 

Physicians can enroll as an individual, group, or as a performing provider into a clinic/group

 

practice. Otorhinolaryngologists who provide itting and dispensing services are no longer

 

required to submit a separate enrollment application to dispense hearing aids.

Traditional

Physician Assistant (PA). To enroll in Texas Medicaid, a PA must be licensed as a PA and

Services

be recognized as a PA by the Texas Physician Assistant Board. All PAs are enrolled within

 

the categories of practice as determined by the Texas Medicaid Board. PAs can enroll as an

 

individual, group, or as a performing provider into a clinic/group practice. If enrolling into a

 

Medicare enrolled clinic/group practice, Medicare enrollment is required.

Traditional

Physiological Lab. To enroll in Texas Medicaid, radiological and physiological laboratories

Services

and portable X-ray suppliers must be enrolled in Medicare. Both radiological and physiological

 

laboratories must be directed by a physician.

Traditional

Podiatrist. Podiatrists (DPM) must be Medicare-certiied and enrolled as Medicaid providers

Services

are authorized to perform procedures on the ankle or foot as approved by the Texas Legislature

 

under their licensure as a DPM when such procedures would also be reimbursable to a

 

physician (MD or DO) under the Texas Medicaid Program. Podiatrists can enroll as an

 

individual, group or as a performing provider into a clinic/group practice. If enrolling into a

 

Medicare enrolled clinic/group practice, Medicare enrollment is required.

Traditional

Portable X-Ray. To enroll in Texas Medicaid, radiological and physiological laboratories

Services

and portable X-ray suppliers must be enrolled in Medicare. A physician must direct both

 

radiological and physiological laboratories.

Traditional

Prosthetist. Prosthetists must be enrolled in Medicare and licensed by the Texas Board of

Services

Orthotics and Prosthetics as a prosthetist (LP) or prosthetist/orthotist (LPO) to measure,

 

design, fabricate, assemble, it, adjust, or service a prosthesis.

Traditional

Prosthetist/Orthotist – To enroll as a prosthetist/orthotist, you must be licensed as both. Refer

Services

to the Prosthetist and Orthotist sections of these instructions for additional information.

Traditional

Psychologist. To enroll in the Texas Medicaid Program, an independently practicing

Services

psychologist must be licensed by the Texas State Board of Examiners of Psychologists and

 

be enrolled as a Medicare provider. Psychologists can enroll as an individual, group or as a

 

performing provider into a clinic/group practice. If enrolling into a Medicare enrolled clinic/

 

group practice, Medicare enrollment is required.

 

A copy of the psychologist’s license that is not due to expire within 30 days must be submitted

 

with this application.

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Traditional

Qualiied Rehabilitation Professional (QRP). A person who meets one or more of the

Services

following criteria: a) Holds a certiication as an assistive technology professional or a

 

rehabilitation engineering technologist issued by, and in good standing with, the Rehabilitation

 

Engineering and Assistive Technology Society of North America (RESNA); b) Holds a

 

certiication as a seating and mobility specialist issued by, and in good standing with, RESNA;

 

and/or c) Holds a certiication as a certiied rehabilitation technology supplier issued by, and in

 

good standing with, the National Registry of Rehabilitation Technology Suppliers (NRRTS).

 

A copy of the NRRTS/RESNA certiication must be submitted with this application.

Traditional

Radiation Treatment Center. To enroll in Texas Medicaid, Radiation Treatment Centers must

Services

be Medicare-certiied and certiied by HHSC Bureau of Radiation Control.

Traditional

Radiological Lab. To enroll in Texas Medicaid, radiological and physiological laboratories

Services

and portable X-ray suppliers must be enrolled in Medicare. A physician must direct both

 

radiological and physiological laboratories.

Traditional

Renal Dialysis Facility. To enroll in Texas Medicaid, a renal dialysis facility must be Medicare-

Services

certiied in the state that it is located to provide services. Facilities must also adhere to the

 

appropriate rules, licensing, and regulations of the state where they operate.

Traditional

Respiratory Care Practitioner (CRCP). To enroll in Texas Medicaid, a certiied respiratory

Services

care practitioner (CRCP) must be certiied by HHSC to practice under Texas Civil Statutes,

 

Article 4512L. As of January 1, 1988, the National Board for Respiratory Care Exam must

 

be passed to be certiied by HHSC. Medicare certiication is not a prerequisite for Medicaid

 

enrollment.

Traditional

Rural Health Clinic – Hospital, Freestanding. Medicare is required for enrollment as a Title

Services

XIX Rural Health Clinic (RHC).

Traditional

Skilled Nursing Facility. To enroll in Texas Medicaid, the provider must be licensed as a

Services

nursing facility by DADS or by the appropriate state board where services are rendered. he

 

provider must be actively enrolled in Medicare as a skilled nursing facility.

Traditional

Social Worker (LCSW). To enroll in the Texas Medicaid Program independently or as a

Services

clinic/group practice, a licensed clinical social worker (LCSW) must be licensed through the

 

State Board of Social Work Examiners as a LCSW and be enrolled in Medicare. Providers

 

must submit a Medicare Waiver Request if their type of practice and service may never be

 

billed to Medicare. Practitioners holding a temporary license are not eligible to enroll in

 

Medicaid. Social Workers can enroll as an individual, group or as a performing provider into

 

a clinic/group practice. If enrolling into a Medicare enrolled clinic/group practice, Medicare

 

enrollment is required.

Traditional

SHARS – School, Co-op, or School-Based Health Center. To enroll in Texas Medicaid,

Services

school-based health centers, including charter schools, must employ, or contract with,

 

individuals or entities that meet certiication and licensing requirements in accordance with

 

the Texas Medicaid State Plan for SHARS in order to bill and be reimbursed for program

 

services. (See the current Texas Medicaid Provider Procedures Manual, School Health and

 

Related Services.)

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Traditional

Specialized/Custom Wheeled Mobility. A provider supplying items of durable medical

Services

equipment that are powered or manual mobility systems, including seated positioning

 

components, powered or manual seating options, electronic drive control, specialty driving

 

controls, multiple adjustment frame, nonstandard optimizations, and other complex or

 

specialized components for clients.

Traditional

TB Clinic. To enroll in Texas Medicaid, the tuberculosis (TB) clinic must be approved by the

Services

Department of State Health Services (DSHS) Infectious Disease Control Unit Tuberculosis

 

Program (IDCU/TB). he TB clinic must be one of the following: a public entity operating

 

under a Texas Health and Human Services Commission (HHSC) tax identiication number

 

(TB regional clinic), a public entity operating under a non-HHSC tax identiication number

 

(city/county/local clinic), or a non-hospital-based entity for private providers and a provider of

 

TB-related clinic services.

 

To receive a DSHS Tuberculosis and Refugee Health Services Branch Medicaid Provider

 

Application, send a request to the following address: Tuberculosis Elimination Division,

 

ATTN: Financial Services and Medicaid Unit, 1100 West 49th Street, Austin TX 78756-3199, or

 

call 1-512-533-3000 for more information.

 

You must attach a copy of your approval letter from the state of Texas.

Traditional

Vision Medical Supplier (VMS). To enroll in Texas Medicaid, doctors of optometry must

Services

be licensed by the licensing board of their profession to practice in the state where the service

 

was performed, at the time the service was performed, and be enrolled as Medicare (Palmetto)

 

Providers.

 

Texas Medicaid Identiication Form – Case Management Services

 

 

Case Management

Blind Children’s Vocational Discovery & Development Program. he Texas Commission for

Services

the Blind (TCB) is eligible to enroll as a Medicaid provider of case management for blind and

 

visually impaired clients (BVIC) younger than age 16.

Case Management

Case Management for Children and Pregnant Women/ Targeted Case Management

Services

(PWI )/THSteps Medical Case Management Services. Enrollment for Case Management

 

for Children and Pregnant Women is a two-step process. Potential providers must submit

 

a Texas Department of State Health Services (DSHS) Case Management for Children and

 

Pregnant Woman application to the DSHS Health Screening and Case Management Unit.

 

Upon approval by DSHS potential providers must enroll as a Medicaid provider for Case

 

Management for Children and Pregnant Women. Ater the enrollment process is completed,

 

the applicant is notiied, in writing, of the provider status and TPI. he facility must enroll as

 

a group and enroll registered nurses and social workers as performing providers of the group.

 

he Provider Agreement, Provider Information Form (PIF-1) and Principal Information

 

Form (PIF-2) must be completed for each principal of the group and each performing provider

 

enrolling into the group.

 

You must attach a copy of your approval letter from DSHS if you are enrolling as a new group

 

or individual.

 

Note: THSteps Medical Case Management (MCM) and Targeted Case Management for High

 

Risk Pregnant Women and High Risk Infants (PWI) Programs are combined with the Case

 

Management for Children and Pregnant Women (CPW) Program.

 

 

Page xviii

Enrollment Application Instructions

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Item

Instructions

Case Management

Early Childhood Intervention (ECI). To participate in Texas Medicaid, an ECI provider must

Services

comply with all applicable federal, state, local laws, and regulations about the services provided.

 

Contractors must be certiied by the Texas ECI program and must submit a copy of the current

 

contract award from the Texas ECI program.

 

You must attach a copy of your approval letter from the Interagency Council on Early

 

Childhood Intervention.

Case Management

Home and Community Based Service–Adult Mental Health (HCBS-AMH). To enroll in

Services

Texas Medicaid, a HCBS-AMH provider must be approved by DSHS. HCBS-AMH providers

 

must enroll as a facility and are not required to enroll in Medicare.

 

HCBS-AMH providers must submit proof of approval and adhere to the appropriate rules,

 

licensing and regulations of the state in which they operate.

Case Management

Intellectual and Developmental Disability Case Management (IDD)–Local Intellectual and

Services

Developmental Disability Authority (LIDDA). To enroll in Texas Medicaid, LIDDA providers

 

of IDD case management must contact the Department of Aging and Disability Services

 

(DADS) at 1-512-438-3011 for approval. LIDDA providers are eligible to become providers of

 

IDD case management with the approval of DADS.

 

You must attach a copy of your approval letter from the state of Texas.

Case Management

Mental Health (MH) Case Management–Local Mental Health Authority (LMHA).

Services

To enroll in Texas Medicaid, LMHA providers must contact the Department of State Health

 

Services (DSHS) at 1-512-206-5288 to be approved. LMHA providers are eligible to become

 

providers of MH case management services with the approval of DSHS.

 

You must attach a copy of your approval letter from the state of Texas.

Case Management

MH Rehabilitative Services–LMHA. To enroll in Texas Medicaid, MH Rehabilitative

Services

ServicesLMHA providers must contact DSHS at 1-512-206-5288 to be approved. LMHA

 

providers are eligible to become providers of MH rehabilitative services with the approval of

 

DSHS.

 

You must attach a copy of your approval letter from the state of Texas.

Case Management

MH Case Management/MH Rehabilitative Services–Non-LMHA. Non-LMHAs are private

Services

providers of both MH case management and MH rehabilitative services, but they are not

 

LMHAs. hey must comply with all applicable federal and local laws and all of the regulations

 

that are related to the services they provide. Ater receiving approval for enrollment in Texas

 

Medicaid, the Non-LMHA provider must be credentialed by a Texas Medicaid managed care

 

organization (MCO) to provide services to Texas Medicaid clients.

 

Note: Non-LMHA providers must register to use the Department of State Health Services (DSHS)

 

Clinical Management for Behavioral Health Services (CMBHS) clinical record-keeping system

 

before providing services to Texas Medicaid clients.

Case Management

Women, Infant, & Children (WIC) (Immunization Only). To be eligible as a qualiied

Services

provider for presumptive eligibility determinations the following federal requirements must

 

be met. he provider must be 1) an eligible Medicaid provider; 2) provide outpatient hospital

 

services, rural health clinic services, or clinic services furnished by or under the direction of

 

a physician without regard to whether the clinic itself is administered by a physician (includes

 

family planning clinics); and 3) receive funds from or participate in the WIC program.

Page xix

Enrollment Application Instructions

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Item

Instructions

Case Management

Youth Empowerment Services (YES) Waiver. To enroll in Texas Medicaid, YES Waiver

Services

providers must contact DSHS at YESWaiver@dshs.state.tx.us to be approved. Upon approval

 

by DSHS potential providers must enroll as a Medicaid provider for YES Waiver.

 

You must attach a copy of your YES Waiver DSHS contract.

Texas Medicaid Identiication Form – Comprehensive Care Program (CCP) Services

CCP Services

Dietitian. Independently practicing licensed dietitians may enroll in Texas Medicaid to

 

provide services to CCP clients. Providers of nutritional services and counseling must be

 

licensed by the Texas State Board of Examiners of Dietitians in accordance with the Licensed

 

Dietitians Act, Article 4512h.

CCP Services

Financial Management Services Agency (FMSA). To enroll in Texas Medicaid, FMSA

 

providers must submit their contract with the Department of Aging and Disability Services as

 

a Financial Management Services Agency provider.

CCP Services

Licensed Vocational Nurse (LVN). Independently enrolled licensed vocational nurses may

 

also enroll to provide private duty nursing (PDN) under Texas Medicaid CCP. In order to

 

enroll, the LVN must submit a plan of RN supervision, including the name and license number

 

of the RN providing the supervision.

CCP Services

Milk Donor. To enroll in Texas Medicaid, the provider must adhere to quality guidelines

 

consistent with the Human Milk Bank Association of Northern America.

CCP Services

Occupational herapist (OT-CCP). HHSC allows Medicaid enrollment of independently

 

practicing licensed occupational therapists in CCP. Licensed HCSSAs are also able to provide

 

occupational therapy in CCP.

CCP Services

Pharmacy. Pharmacy providers are eligible to enroll in CCP. To be enrolled in CCP, the

 

pharmacy must irst be enrolled in the Texas Medicaid Vendor Drug Program (VDP).

 

Pharmacies enrolling as CCP-only providers do not require Medicare certiication to enroll.

 

Only taxonomy code 336000000X is available for selection during the enrollment process.

 

See “Traditional Services – Pharmacy Group” for additional information about pharmacies.

CCP Services

Physical herapist (PT-CCP). he Medicare enrollment requirement is waived for therapists

 

providing services only to THSteps-eligible clients who are 20 years of age and younger and

 

who are not receiving Medicare beneits. Physical therapy services may also be provided by

 

a licensed HCSSA. CCP physical therapy may be provided by either a licensed and certiied

 

home health provider or licensed HCSSA, and physical therapy through Medicaid home health

 

services may be provided by a licensed and certiied HCSSA.

CCP Services

Prescribed Pediatric Extended Care Center. To enroll in the Texas Medicaid Program, a

 

Prescribed Pediatric Extended Care Center (PPECC) provider must be licensed by the Texas

 

Department of Aging and Disability Services (DADS). PPECC providers must enroll as a

 

facility and are not required to enroll in Medicare.

 

PPECC providers must submit proof of their licensure and adhere to the appropriate rules,

 

licensing and regulations of the state in which they operate.

CCP Services

Registered Nurse (RN). Independently enrolled registered nurses may also enroll to provide

 

private duty nursing under CCP.

Page xx

Enrollment Application Instructions

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Item

Instructions

CCP Services

Service Responsibility Option (SRO). To enroll in the Texas Title XIX Medicaid Program,

 

Service Responsibility Option providers must complete the Texas Medicaid enrollment

 

application. Providers of personal assistance services must submit their contract with the

 

Department of Aging and Disability Services as a Service Responsibility Option provider.

CCP Services

Speech herapist (SLP). HHSC allows enrollment of independently practicing licensed speech-

 

language pathologists under the THSteps-CCP. Texas Medicaid enrolls and reimburses speech-

 

language pathologists for CCP services only.

Texas Medicaid Identiication Form – Other Texas Medicaid Services

Texas Health Steps

Check the box on page 1-3 if you elect not to participate as a provider for THSteps preventive

(THSteps) services

medical checkups. If you decided at a later time to participate as a provider for THSteps

(i.e., EPSDT)

preventive medical checkups, you will be required to complete and submit the THSteps

 

Provider Enrollment Application that is available on the TMHP website at www.tmhp.com.

 

By leaving this box unchecked, you may be issued a THSteps medical provider identiier in

 

addition to the provider identiier for your requested provider type. To enroll in the THSteps

 

program, a provider must be a licensed physician (MD, DO); physician assistant (PA); clinical

 

nurse specialist (CNS); nurse practitioner (NP); certiied nurse midwife (CNM); federally

 

qualiied health centers (FQHC); health-care provider of a facility (public or private) capable

 

of performing the required medical checkup procedures under the direction of a physician;

 

(such as a regional and local health department; family planning clinic; migrant health clinic;

 

community-based hospital and clinic; maternity clinic; rural health clinic; home health agency;

 

or school-based health center).

Texas Vaccines for

Check the appropriate boxes in response to the questions. Providers that provide routinely

Children Program

recommended vaccines to children who are 18 years of age and younger can apply to receive

(TVFC)

free vaccines from TVFC. he TVFC Provider Agreement is available in the forms section of

 

the TVFC website at www.dshs.texas.gov/immunize/tvfc/ProviderResources.shtm.

Texas Medicaid Provider Enrollment Application

A.1 - A.3 Provider

his section is for provider demographic information. Provide complete and correct

of Services

information as required.

Information

 

A.4 Healthy Texas

Choose the appropriate statement.

Women (HTW)

If you will be rendering services for HTW clients, you must complete and submit the Healthy

 

 

Texas Women Certiication form with this application. his form must be completed and

 

submitted by providers that render women’s health and family planning services to clients who

 

participate in the Healthy Texas Women program. An original signature is required. his form

 

cannot be faxed to TMHP. he form is located in Appendix A of this application.

 

Important: Under Texas Human Resources Code, Section 32.024(c-1), and relating program

 

rules in the Texas Administrative Code, the provider or the provider’s ailiated organization is

 

not qualiied to participate in and is ineligible to bill for services provided through the Healthy

 

Texas Women program if the provider or anyone in the provider’s organization performs

 

or promotes elective abortions, or is an ailiate of another entity that performs or promotes

 

elective abortions.

Page xxi

Enrollment Application Instructions

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Item

Instructions

B.1 - B.2

Completion and submission of this form is a condition of participation, certiication or

Disclosure of

recertiication under any of the programs established by Titles V, XVIII, XIX, and XX or as a

Ownership and

condition of approval or renewal of a contractor agreement between the disclosing entity and

Control Interest

the secretary of appropriate state agency under any of the above-titled programs, a full and

Statement

accurate disclosure of ownership and inancial interest is required. Failure to submit requested

 

information may result in a refusal by the appropriate State agency to enter into an agreement

 

or contract with any such institution in termination of existing agreements.

 

Note: Each creditor 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% of the provider’s property must be listed in this form.

 

Every individual and entity on the list must complete and submit a PIF-2 form.

B.3 PIF-2

A separate copy of the Principal Information Form (PIF-2) must be completed in full for each

 

principal, subcontractor, and creditor of the Provider, before enrollment.

C. Group Practice

Group practice information. If this enrollment is for a group practice, please complete Section

 

C, and provide complete and correct information as required.

D. PIF-1

Each Provider must complete the Provider Information Form (PIF-1), before enrollment.

 

Important: he physical address is where health care is rendered. In the Physical Address

 

ield, providers MUST enter the physical address where the services are rendered to clients; the

 

accounting, corporate, or mailing address must NOT be entered in the physical address ield. If a

 

site visit is required and cannot be conducted because the physical address was not provided, the

 

enrollment application will be denied.

HHSC Medicaid

Complete the required information at the beginning of the form, read the agreement

Provider

information, and sign and date the agreement to indicate that you have read and agree with the

Agreement

terms of enrollment as required by the Texas HHSC.

 

Important: he physical address is where health care is rendered. In the Physical Address

 

ield, providers MUST enter the physical address where the services are rendered to clients; the

 

accounting, corporate, or mailing address must NOT be entered in the physical address ield. If a

 

site visit is required and cannot be conducted because the physical address was not provided, the

 

enrollment application will be denied.

IRS W–9 Form

Provide complete and correct information as required.

 

 

Page xxii

Enrollment Application Instructions

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

ADDITIONAL INSTRUCTIONS - APPENDIX A

he following are instructions for the additional attachments available in Appendix A:

Item

Instructions

Corporate Board of

his form is required if the enrolling provider is incorporated. his form must be

Directors Resolution

notarized, and an original signature is required. his form cannot be faxed to TMHP.

Medicaid Audit

his form must be completed and submitted by facilities.

Information Form

 

Physician Letter of

Upon initial enrollment and upon revalidation every 5 years, the CNM or LM must

Agreement for Certiied

complete and submit to TMHP with the enrollment application this agreement airming

Nurse Midwife (CNM) and

the LM’s referring or consulting physician arrangement or the CNM’s supervising

Licensed Midwife (LM)

physician arrangement. A separate agreement must be submitted for each referring

Providers

or consulting physician with whom an arrangement is made. his agreement must be

 

signed by the CNM or LM and the referring or consulting physician.

 

A new agreement must also be completed and submitted to TMHP when a new

 

arrangement is made and when changes to an arrangement are made. he new

 

agreement must be submitted to TMHP with all appropriate signatures within 10

 

business days of a cancellation or change.

Electronic Funds Transfer

To enroll in the EFT program, complete the attached Electronic Funds Transfer (EFT)

(EFT) Notiication

Notiication. You must return a voided check or signed letter from your bank on bank

 

letterhead with the notiication to the TMHP address indicated on the form.

Healthy Texas Women

Refer to the HTW instruction box above for additional information.

Certiication

 

he following forms must be obtained from other sources and submitted with this application as appropriate for the requested provider type:

Franchise Tax Account Status

his certiicate must be obtained from the Texas State Comptroller’s Oice website at https://mycpa.cpa.state.tx.us/coa/Index.html.

here is no charge for this request.

Providers who answer “yes” to the question “Do you have a 501(c) (3) Internal Revenue Exemption” must submit a copy of their IRS Exemption Letter with submission of this application’s signature page. Providers who have a 501(c)(3) Internal Revenue Exemption are not required to submit a copy of the Franchise Tax Account Status Page from the State Comptroller’s Oice.

Page xxiii

Enrollment Application Instructions

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

CONTACT INFORMATION – POINT OF CONTACT FOR THIS APPLICATION

Provide a point of contact for questions about this application, and include an alternate address if deiciency letters should be mailed somewhere other than the physical address identiied on this application as the location where Medicaid services are being provided.

Contact Name: Last

First

Middle Initial

Contact Telephone Number:

Contact Fax (if applicable):

Email Address (if applicable):

Address: Number

Street

Suite No.

City

State

ZIP Code

Page xxiv

Enrollment Application Instructions

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

MEDICARE ENROLLMENT INFORMATION

REQUIRED: Medicare enrollment is a prerequisite for Medicaid enrollment if you render services for clients who are eligible for Medicare.

Are you using a Medicare certiication number for this enrollment?

Yes

No

Important: Do not continue with this application if your Medicare certiication is pending. Once you have received a Medicare certiication number, you may submit an application (an online application is recommended) for enrollment into Texas State Health-Care Programs. Your enrollment efective date will be retroactive to your Medicare certiication date. Claims submitted by newly-enrolled providers must be received within 95 days of the date the new provider identiier is issued, and within 365 days of the date of service.

MEDICARE WAIVER REQUEST

If you are eligible to request a Medicare waiver, choose one of the following and continue with this application:

FI certify my practice is limited to individuals birth through 20 years of age. I understand if Medicare certiication is obtained during or ater the completion of the Texas State Health-Care Programs enrollment application,

I will be required to submit a new enrollment application listing this Medicare certiication information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. A signed Explanation / Justiication letter on company letterhead must be submitted to TMHP with submission of this application’s signature page for consideration of the Medicare Waiver Request.

FI certify that the service(s) I render is / are not recognized by Medicare for reimbursement. I further certify the claims for these services will not be billed to Medicare (this includes Medicare crossover claims). I understand if Medicare certiication is obtained during or ater the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certiication information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. A signed Explanation / Justiication letter on company letterhead must be submitted to TMHP with submission of this application’s signature page for consideration of the Medicare Waiver Request.

MEDICARE BILLING ACKNOWLEDGEMENT STATEMENT

You must check the box below if you are a provider who is not using a Medicare certiication number for this enrollment.

FI understand that the services that are provided to Medicare-eligible clients cannot be billed to Medicaid unless Medicare is billed irst. If the services are not billed to Medicare irst, Medicaid may recoup payments for the services. I also understand that I cannot bill the client for these services.

Page xxv

Enrollment Application Instructions

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

SURETY BOND INFORMATION

Surety Bond Information

REQUIRED: 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).

Are you a government owned or operated entity?

Yes, I understand that proof of my government owned or operated status must be received before

my application will be considered complete.

No

Note: If you are a government owned or operated entity then a surety bond is not required.

Are you requesting a waiver from the surety bond requirement?

Yes, I understand that a signed explanation/justification letter on company letterhead requesting the surety bond waiver must be received before my application will be considered complete.

No

* The Surety Bond Form can be found on the TMHP website at www.tmhp.com/Pages/Medicaid/medicaid_forms.aspx.

Page xxvi

Enrollment Application Instructions

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

APPLICATION PAYMENT FORM

In accordance with ACA and 42 CFR 455.460, certain providers are subject to an application fee for all applications, including, but not limited to:

Initial applications for new enrollment

Applications for a new practice location

Applications received in response to re-enrollment

An application fee is not required and will not be accepted if the provider is enrolled in Medicare, another State’s Medicaid program, or another Texas State agency. Providers will be required to submit details and/or payment of other programs or agencies to TMHP with submission of this application.

I AM NOT USING A MEDICARE NUMBER FOR THIS ENROLLMENT

INSTRUCTIONS: If you are not using a Medicare certification number for this enrollment, select ONE of the following:

FI am submitting the application fee to Texas Medicaid by paper check, money order, or cashier’s check with this application.

NOTE: Providers must include a check, money order, or cashier’s check with their Texas Medicaid provider enrollment packet submission for the application fee. Cash cannot be accepted. Make the check payable in the amount of $560.00 to Texas Medicaid & Healthcare Partnership (TMHP). Include the Portal Ticket Number on the check and print the PEP Cover letter. Mail the printed PEP Cover letter with the check.

FI attest that I have already paid the application fee to another state’s Medicaid program or CHIP program and have been approved for enrollment in another state’s Medicaid program or CHIP program. My proof of payment and enrollment is attached to this application. I understand that if my proof of payment to another state’s Medicaid program or CHIP program is found to be unacceptable for any reason, I may be required to pay an application fee towards my Texas Medicaid enrollment application.

FI am requesting an application fee waiver due to inancial hardship. My documentation that supports my request is attached to this application. I understand that I must submit a letter (and supporting documentation) with my enrollment application that details the reason(s) I am unable to pay an application fee. I understand that if the waiver request is denied, I will be required to submit an application fee if I wish to proceed with the Texas Medicaid enrollment process.

NOTE: If hardship waiver was issued by another state, you must also request a waiver from Texas Medicaid.

FThe application fee is not applicable for my provider type.

Page xxvii

Application Payment Form

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

TEXAS MEDICAID IDENTICATION FORM

TYPE OF ENROLLMENT:

New enrollment (new provider, practice location, etc.)

Provider re-enrollment

REQUESTING ENROLLMENT AS:

Select only one of the following options. Selecting more than one of the following options may result in a delay in processing this enrollment application.

Individual

Facility

Group

Performing Provider

Note: For group enrollment, single-specialty groups must choose a specialty from the services list below. Clinic/group practices must choose “Clinic/Group Practice” from the services list below.

LIST NPI: ______________________________________________________________________

(NPI not required for Financial Management Services Agency [FMSA], Milk Donor Bank, Personal Assistance Services, and Service Responsibility Option [SRO])

ADDITIONAL ENROLLMENT:

I do not wish to participate as a provider in the CSHCN Services Program.

Please check only the appropriate box to ensure proper enrollment. For assistance in choosing the appropriate provider type, please refer to the instructions.

PROVIDER TYPE:

TRADITIONAL SERVICES

 

 

F

Ambulance/Air Ambulance ★ ✚ ▲

F

Community Mental Health Center

F

Ambulatory Surgical Center (ASC) ★ ✚ ▲

F

Comprehensive Health Center (CHC)

F

Anesthesiologist Assistant ★ ✪ ▲

F

Comprehensive Outpatient Rehabilitation

F Audiologist ★ ✪ ▲

 

Facility (CORF)

 

 

F

Birthing Center

F Dentist/Doctor of Dentistry as a Limited

 

Physician ★ ✪ ▲

 

 

 

F

Catheterization Lab

F Durable Medical Equipment (DME) R

 

 

F Certiied Nurse Midwife (CNM) ★ ▲ t

F Family Planning Agency ✚ t

 

 

F Certiied Registered Nurse Anesthetist

F Federally Qualiied Health Center (FQHC) ★ t

 

(CRNA) ★ ▲

 

 

 

F

Chemical Dependency Treatment Facility

F Federally Qualiied Look-alike (FQL) t

 

 

F

Chiropractor ★ ▲

F Federally Qualiied Satellite (FQS) ★ t

 

 

F

Clinic/Group Practice ★ ✪ t

F

Freestanding Psychiatric Facility ✚ ▲ ★

 

 

F Freestanding Rehabilitation Facility

Continued on next page

LEGEND: Approval Letter/Contract required

Eligible for Medicare waiver request

(you must check a Medicare waiver request box on page xxv)

License/certiication required

RProof of ingerprinting required

Medicare number required

Must designate if public provider

Palmetto number required

tHealthy Texas Women (HTW)

(Healthy Texas Women Certiication required for reimbursement)

Page 1-1

Texas Medicaid Identiication Form

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Continued from previous page

FGenetics ✚ ▲

FHCSSA

FHearing Aid R

FHome Health ★ ▲ R

FHospital — In-State ✚ ▲ ★

FHospital Ambulatory Surgical Center (HASC)

FHospital — Military ✚ ▲ ★

FHospital — Out-of-State ✚ ▲ ★

FHyperalimentation R

FIndependent Diagnostic Testing Facility (IDTF) ★ ✚

FIndependent Lab (No Physician Involvement) ★ ✚

FIndependent Lab (Physician Involvement) ★ ✚

FLicensed Marriage and Family herapist (LMFT)

FLicensed Professional Counselor (LPC)

FLicensed Midwives ▲ t

FMaternity Service Clinic (MSC) ✚ t

FNurse Practitioner/Clinical Nurse Specialist (NP/CNS) ★ ✪ ▲ t

FOccupational herapist (OT) ★ ▲

FOptician

FOptometrist (OD) ★ ✪ ▲

FOrthotist ★ ✪ ▲

FOutpatient Rehabilitation Facility (ORF)

FPersonal Assistant Services/PCS

FPharmacy Group

FPharmacist ★ ▲

FPhysical herapist (PT) ★ ▲

FPhysician (MD, DO) ★ ✪ ▲ t

OB/GYN and Pediatricians not required to have a Medicare Number

FPhysician Assistant ★ ✪ ▲ t

FPhysiological Lab

FPodiatrist ★ ▲

FPortable X-Ray

FProsthetist ★ ✪ ▲

FProsthetist - Orthotist (choose if licensed as both) ★ ✪ ▲

FPsychologist ★ ▲

FQualiied Rehabilitation Professional (QRP)

FRadiation Treatment Center

FRadiological Lab

FRenal Dialysis Facility ★ ✚ ▲

FRespiratory Care Practitioner (CRCP)

FRural Health Clinic – Hospital, Freestanding ★ ✚ t

FSkilled Nursing Facility ★ ▲

FSocial Worker (LCSW) ★ ✪ ▲

FSHARS — School, Co-op, or School-Based Health Center

FSpecialized/Custom Wheeled Mobility R

FTB Clinic ✚ ●

FVision Medical Supplier (VMS)

LEGEND: Approval Letter/Contract required

Eligible for Medicare waiver request

(you must check a Medicare waiver request box on page xxv)

License/certiication required

RProof of ingerprinting required

Medicare number required

Must designate if public provider

Palmetto number required

tHealthy Texas Women (HTW)

(Healthy Texas Women Certiication required for reimbursement)

Page 1-2

Texas Medicaid Identiication Form

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

CASE MANAGEMENT SERVICES

F Blind Children’s Vocational Discovery & Development

F

Mental Health (MH) Case Management–Local Mental

 

Program ●

 

Health Authority (LMHA)

F Case Management for Children and Pregnant

F

MH Rehabilitative Services–LMHA

 

Women ▲ ●

F

MH Case Management/MH Rehabilitative

F Early Childhood Intervention (ECI)

 

Services–Non-LMHA

F

Financial Management Services Agency (FMSA) ●

F

Service Responsibility Option (SRO) ●

F Home and Community Based Service - Adult Mental

F

Women, Infants & Children (WIC) – Immunization

 

Health (HCBS-AMH)

 

Only ●

F Intellectual and Developmental Disability (IDD) Case

F

Youth Empowerment Services (YES)

 

Management–Local Intellectual and Developmental

 

Waiver

 

Disability Authority (LIDDA)

 

 

COMPREHENSIVE CARE PROGRAM (CCP) SERVICES

 

 

 

 

 

F

Dietician ▲

F

Physical herapist (PT-CCP)

F Licensed Vocational Nurse (LVN) ▲

F

Prescribed Pediatric Extended Care Center ▲ R

F

Milk Donor

F

Registered Nurse (RN) ▲

F Occupational herapist (OT-CCP)

F

Speech herapist (SLP) ▲

FPharmacy ●

TEXAS HEALTH STEPS (THSTEPS) SERVICES (EPSDT)

FI do not wish to participate as a provider for THSteps preventive medical checkups.

TEXAS VACCINES FOR CHILDREN PROGRAM (TVFC)

Texas Medicaid does not reimburse for vaccines available from Texas Vaccines for Children (TVFC) program.

F Yes

F No

Do you currently receive free vaccines from TVFC? (if No, answer the next question)

F Yes

F No

Does your clinic/practice provide routinely recommended vaccines to children birth through

 

 

18 years of age? (If Yes, complete the Texas Vaccines for Children Program Provider Agreement

 

 

available at www.dshs.texas.gov/immunize/tvfc/ProviderResources.shtm.)

LEGEND: ● Approval Letter/Contract required

Eligible for Medicare waiver request

(you must check a Medicare waiver request box on page xxv)

License/certiication required

RProof of ingerprinting required

Medicare number required

Must designate if public provider

Palmetto number required

tHealthy Texas Women (HTW)

(Healthy Texas Women Certiication required for reimbursement)

Page 1-3

Texas Medicaid Identiication Form

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

TEXAS MEDICAID PROVIDER ENROLLMENT APPLICATION

All information must be completed and contain a valid signature to be processed. If a question or answer does not apply, enter “N/A”.

Use blue or black ink.

SECTION A: PROVIDER OF SERVICE INFORMATION

All applicants, complete the following information.

A.1 PROVIDER TYPE SPECIC INFORMATION

he applicant (individual, facility, group, or performing provider) must complete the following questions as applicable.

Name of Provider Enrolling:

 

 

 

Group/Company or Last Name

First

Middle Initial

 

 

 

 

 

Public/Private entities:

Deinition — Public entities are those that are owned or operated by a city, state, county, or other

(required of all providers)

government agency or instrumentality, according to the Code of Federal Regulations, including any

 

agency that can do intergovernmental transfers to the State. Public agencies include those that can certify

 

and provide state matching funds.

 

 

 

 

 

 

 

Are you a private or public entity?

F Private

F Public

 

 

 

 

 

If you are a public entity, are you required to certify expended

F Yes

F No

 

funds?

 

 

 

 

 

 

 

 

Name and address of a person certifying expended funds:

 

 

 

 

 

 

 

Is this a freestanding facility?

F Yes

F No

 

 

 

 

 

Is this a hospital-based facility?

F Yes

F No

Facilities only:

 

 

 

Is this an ESRD facility?

F Yes

F No

 

 

 

 

 

If Yes, what is your composite rate?

 

 

 

 

 

 

 

Do you provide hearing services for children?

F Yes

F No

Hearing aid providers only:

 

 

 

Will you be itting and dispensing hearing aids?

F Yes

F No

 

 

 

 

 

 

Are you enrolling as a school district?

F Yes

F No

 

 

 

 

 

If Yes, give school six-digit T.E.A. number:

 

 

 

 

 

 

School Health and Related

Are you enrolling as a special education co-op?

F Yes

F No

If Yes, attach a list of all school districts in the co-op that will be

 

 

 

 

 

Services (SHARS) providers

providing SHARS services. Provide the following information for each

 

 

only:

school district:

 

 

 

omplete address

 

 

 

chool District Number

 

 

 

.E.A. number.

 

 

 

 

 

 

Page 2-1

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

 

Are you a hospital facility?

F Yes F No

 

 

 

If Yes, indicate the type of hospital facility.

 

F Children’s

F Teaching Facility

F Long Term

 

 

F Short Term

F Private Full Care

F Private Outpatient

 

F Psychiatric

F Rehabilitation

F State Owned

 

Hospital providers only:

 

 

 

 

 

 

Do you have children’s unit(s)?

 

 

F Yes

F No

 

 

 

 

 

 

 

 

Date of Construction?

 

 

 

 

 

 

 

 

 

 

 

 

 

If you are a hospital facility, what is your average daily room rate

Private

 

Semi-Private

 

 

 

 

 

for private and semi-private?

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Beds:

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you ofer telemonitoring services?

F Yes

F No

 

 

 

 

By checking yes, I certify my organization or facility has all of the necessary equipment and devices

Home Health and Hospital

to render telemonitoring services. I certify that all telemonitoring staf are qualiied to install the

needed telemonitoring equipment and to monitor the client data that is transmitted according

providers only:

to the client’s care plan. I certify that my organization or facility has written protocols, policies,

 

 

and procedures on the provision of home telemonitoring services, and those written protocols,

 

policies, and procedures are available to the Health and Human Services Commission (HHSC) or

 

its designee upon request

 

 

 

 

 

 

 

 

 

Are you licensed as a Physician Assistant (PA) or a Nurse recognized as an Advanced

 

THSteps and Family Planning

Practice Registered Nurse (APRN)?

F Yes

F No

 

 

 

 

 

 

 

 

 

Providers Only

If Yes please list the appropriate Sub-Specialty in section A.2. (Certiied Nurse Midwife (CNM),

 

 

Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), or PA).

 

 

 

A.2 PROVIDER SPECIALTY/TAXONOMY INFORMATION

he applicant (individual, facility, group, or performing provider) must complete the following questions as applicable.

Primary Specialty:

Sub-Specialty: (if applicable)

Primary Taxonomy Code:

If the applicant is a performing provider, complete the following:

Group TPI: (if enrolling as a performing provider into an existing group)

Group Medicare Number: (if applicable)

Page 2-2

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

A.3 PROVIDER DEMOGRAPHIC INFORMATION

he applicant (individual, facility, group, or performing provider) must complete the following questions as applicable.

Existing Texas Provider Identiiers (TPIs): (List all TPIs associated with the individual/group/facility enrolling)

Group/Company DBA Name:

 

Title/Degree:

 

Do you want to be a limited provider?

 

 

 

 

 

(see Useful Information)

 

 

 

 

 

F Yes F No

 

 

 

 

Provider business e-mail: (if applicable)

Provider website address: (if applicable)

 

 

 

 

 

 

 

 

Telephone number:

 

Physical address FAX number:

 

 

 

 

 

 

 

 

Legal name according to the IRS:

 

Accounting/billing address FAX number: (optional)

(must match the legal name ield on the W-9 and Disclosure of

 

 

 

Ownership)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal/Employer Tax ID number:

 

 

 

 

 

 

 

 

Accepting new clients:

 

Gender served:

Client age restrictions:

 

 

 

 

 

 

 

F Yes F No

 

F Male F Female F All

 

 

 

 

 

 

 

 

 

Counties served:

 

 

 

 

Indicate your reason for applying to join the Texas State Health-Care Programs: (Select one)

FAccess to an online application

FAdding a new location

FAdding performing provider to an existing group

FElectronic claims processing

FImproved administrative processes

FIncentive programs

FLearned about Texas State Health-Care Programs at a conference

FLearned about Texas State Health-Care Programs at a provider workshop

FRecruited by Texas State Health-Care Programs staf

FRecruited by TMHP Provider Relations representative

FRe-enrolling a provider under an existing provider identiier

FReimbursement increases

FTimely reimbursement

A.4 CHILDRENS HEALTH INSURANCE PROGRAM

Are you enrolling to provide services exclusively to CHIP clients? F Yes F No

I would like my information to be visible on the TMHP Online Provider Lookup (OPL). F Yes F No

A.5 HEALTHY TEXAS WOMEN (HTW)

Choose one of the following:

FI do not provide services for HTW clients.

FI provide services for HTW clients. (If you provide services for HTW clients, you must complete the Healthy Texas Women Certiication in Appendix A.)

Page 2-3

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

SECTION B: DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT

B.1 DISCLOSURE OF OWNERSHIP INSTRUCTIONS

Completion and submission of this form is a condition of participation, certiication or recertiication under any of the programs established by Titles V, XVIII, XIX and XX or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the secretary of appropriate state agency under any of the above-titled programs, a full and accurate disclosure of ownership and inancial interest is required. Failure to submit requested information may result in a refusal by the appropriate State agency to enter into an agreement or contract with any such institution in termination of existing agreements.

GENERAL INSTRUCTIONS

Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under the Remarks Section referencing the item number to be continued. If additional space is needed, use an attached sheet.

DETAILED INSTRUCTIONS

hese instructions are designed to clarify certain questions on the form. Instructions are listed in order of question for easy reference. NO instructions have been given for questions considered self- explanatory.

IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT.

ITEM I – Identifying Information

(a)Under identifying information specify in what capacity the entity is doing business as (DBA), example, and name of trade or corporation.

ITEM II Self–explanatory.

ITEM III – Owners, Partners, Oicers, Directors, and Principals List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity. 501 (c) (3) nonproit and state-owned entities must list the oicers or directors that have a control interest in the entity and managing employees in Section III(a). Since there will be no entries for any person with an ownership interest (Section III[b]), the percentage of ownership will always be less than 100 percent.

Direct ownership interest is deined as the possession of stock, equity in capital or any interest in the proits of the disclosing entity. A disclosing entity is deined as a Medicare provider or supplier or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program or health related services under the social services program.

Indirect ownership interest is deined as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity. he amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity. Example: if “A” owns 25 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, “A’s” interest equates to a 20 percent indirect ownership and must be reported.

Controlling interest is deined as the operational direction or management of a disclosing entity which may be maintained by any or all of the following devices; the ability or authority, expressed or reserved to amend or change the corporate identity (i.e., joint venture

agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved to amend or change the by-laws, constitution or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved to control the sale of any or all of the assets to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity or to arrange for the sale or transfer of the disclosing entity to new ownership or control.

Note: ALL INDIVIDUALS LISTED IN SECTION III(A) MUST SUBMIT A PIF-2.

ITEMS IV through VII – Changes in Provider Status

Change in provider status is deined as any change in management control. Examples of such changes would include a change in Medical or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of the owning partnership which under applicable State law is not considered a change in ownership, or the hiring or dismissing of any employees with 5 percent or more inancial interest in the facility or in an owning corporation, or any change of ownership.

For items IV through VII, if the Yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued.

ITEM IV – Ownership

(a & b) If there has been a change in ownership within the last year or if you anticipate a change, indicate the date in the appropriate space.

ITEM V – Management

If the answer is Yes, list name or the management irm and employer identiication number (EIN) or the leasing organization. A management company is deined as any organization that operates and names a business on behalf of the owner of that business with the owner retaining ultimate legal responsibility for operation of the facility.

ITEM VI – Staing

If the answer is Yes, identify which has changed (Administrator, Medical Director or Director of Nursing) and the date the change was made. Be sure to include name of the new administrator, Director of Nursing or Medical Director, as appropriate.

ITEM VII – Ailiation

A chain ailiate is any freestanding health-care facility that is owned, controlled, or operated under lease or contract by an organization consisting of two or more freestanding health-care facilities organized within or across State lines which is under the ownership or through any other device, control and direction of a common party. Chain ailiates include such facilities whether public, private, charitable or proprietary. hey also include subsidiary organizations and holding corporations. Provider-based facilities such as hospital–based home health agencies are not considered to be chain ailiates.

ITEM VIII – Capacity

If the answer is Yes, list the actual number of beds in the facility now and the previous number.

ITEM IX - Disclosure of Relationship

Please disclose any of familial relationships between principals and/ or the provider (i.e., Husband, Wife, Natural or Adoptive Parent, Natural or Adoptive Child, Natural or Adoptive Sibling).

Page 2-4

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

B.2 DISCLOSURE OF OWNERSHIP FORM (3 PAGES)

his form is required for all individuals, groups, and facilities (exclude performing providers and SHARS providers).

I.Identifying information

(a)

Legal Name: (according to the IRS)

DBA:

Telephone number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical/Corporate Address:

 

 

 

 

 

Number

Street

Suite

City

State

ZIP

II.Answer the following questions by checking Yes or No.

If any of the questions are answered Yes, list names and addresses of individuals or corporations under Remarks on the Disclosure of Ownership and Control Interest Statement form. Identify each item number to be continued.

(a)

Are there any individuals or organizations having a direct or indirect ownership or control interest of ive percent

Yes

No

 

or more in the institution, organizations, or agency that have been convicted of a criminal ofense related to the

 

 

 

involvement of such persons, or organizations, in any of the programs established by Titles XVIII, XIX, or XX?

 

 

 

 

 

 

(b)

Does this provider have any current employees in the position of manager, accountant, auditor, or in a similar

Yes

No

 

capacity and who were previously employed by this provider’s iscal intermediary or carrier within the last 12

 

 

 

months? (Medicare providers only)

 

 

 

 

 

 

III.Owners, Partners, Oicers, Directors, and Principals

All individuals and entities identiied in this section are required to complete a PIF-2 which must be submitted with this enrollment application.

(a)Identify individuals who are sole proprietors or owners, partners, oicers, directors, and principals (as deined in the Principal Information Form [PIF-2]) of the applicant and list the percentage of ownership, if applicable. Total ownership should equal 100 percent unless otherwise noted in the instructions (see previous page). If ownership does not total 100 percent, the provider must submit a letter explaining the discrepancy. As it relates to owners, include all individuals with 5 percent or more ownership in the company, whether this ownership is direct or indirect.

(Add additional pages if necessary.)

 

1.

Name:

Percentage Owned:

 

 

 

 

 

 

 

 

 

2.

Name:

Percentage Owned:

 

 

 

 

 

 

 

 

 

3.

Name:

Percentage Owned:

 

 

 

 

 

 

 

 

 

4.

Name:

Percentage Owned:

 

 

 

 

 

 

 

 

(b)Identify the entities with ownership of a controlling interest in the applicant (whether such ownership of the controlling interest is direct or indirect). Provide the entity’s name and federal tax identiication number. See Instructions for Completing the Disclosure of Ownership and Control Interest Statement. List any additional names and addresses under Remarks on the Disclosure of Ownership and Control Interest Statement. If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks.

Name:

Address:

Federal Tax ID:

Page 2-5

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

(c)

Do you currently have a creditor with a security interest in a debt that is owed by you?

Yes

No

 

Is the creditor(s) security interest protected by at least 5 percent of your property?

Yes

No

 

 

 

 

List each creditor with a security interest in a debt that is owed by you if the creditor’s security interest is protected by at least 5 percent of your property. All listed creditors must also complete a Principal Information Form (PIF-2).

 

Last Name/Company Name:

First Name:

Percent of Security Interest:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(d)Type of Entity: Select only one - must match entity on W9

Individual/sole proprietor

C Corporation

S Corporation

Partnership

Limited liability company. (Enter the tax classiication [C=C corporation, S=S corporation, P=partnership]) _____________________

Trust/estate

Other (specify) __________________ ___________________________________

(e)If the disclosing entity is a corporation, list names, addresses of the directors and EINs for corporations in remarks.

NOTE: Each director identiied in this section must also complete a PIF-2. All PIF-2 documents must be submitted with this application. Attach additional pages if needed.

Remarks:

IV.

Ownership

 

 

 

 

 

 

(a)

Has there been a change in ownership or control within the last year?

Yes

No

 

 

 

 

 

If Yes, give date:

 

 

(b)

Do you anticipate any change of ownership or control within the year?

Yes

No

 

 

 

 

 

If Yes, give date:

 

 

 

 

 

 

(c)

Do you anticipate iling for bankruptcy within the year? (see provider agreement for additional

Yes

No

 

information)

 

 

 

 

 

 

 

If Yes, give date:

 

 

(d)

Are any of the new owners related to any of the former owners?

Yes

No

 

 

 

 

(e)

Did any former owners transfer their ownership interest to any new owners in anticipation of

 

 

 

or following the assessment of a civil monetary penalty? If yes, please list the name of the former

Yes

No

 

owners below.

 

 

Last Name:

First Name:

Middle Initial:

V.

Management

 

 

 

 

 

 

 

Does the provider identiied in Section I. above comprise or include a facility that is operated by

Yes

No

 

a management company, or a facility that is leased in whole or in part by another organization?

 

 

 

 

 

 

 

 

If Yes, give date of change in operations:

 

 

 

 

 

 

Page 2-6

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

VI.

Staing

 

 

 

 

 

 

(a)

Has there been a change in Administrator, Director of Nursing, or Medical Director within the

Yes

No

 

last year?

 

 

 

 

 

 

 

 

 

 

 

VII.

Ailiation

 

 

 

 

 

 

(a)

Is the provider identiied in Section I. above chain ailiated?

Yes

No

 

 

 

 

If Yes, provide the name, address, and Federal Tax ID number of the chain’s corporate/home oice:

 

Name

 

Address

 

Federal Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VIII.

Capacity

 

 

 

 

 

 

 

 

 

(a)

Have you increased your bed capacity by 10 percent or more or by 10 beds, whichever is greater,

Yes

No

 

within the last two years? (For Hospitals only)

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, give:

Year of change:

Current Beds:

Prior Beds:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IX.

Disclosure of Relationship

 

 

 

 

(a)Please disclose any of the following familial relationships between principals and/or the provider (Husband, Wife, Natural or Adoptive Parent, Natural or Adoptive Child, Natural or Adoptive Sibling):

 

Provider/Principal 1:

Has a Relationship as:

To Provider/Principal Name 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please Note: When claiming “Corporation” providers must complete and return the following forms:

Corporate Board of Directors Resolution Form, original signature and notarized.

Certiicate of Formation, Certiicate of Filing, Certiicate of Authority, or Certiicate of Registration.

Franchise Tax Account Status, available at https://mycpa.cpa.state.tx.us/coa/Index.html.

Do you have a 501(c)(3) Internal Revenue Exemption? Yes No

Providers who answer ”yes” to the question “Do you have a 501©(3) Internal Revenue Exemption” must submit a copy of their IRS Exemption Letter with submission of this application’s signature page. Providers who have a 501(c)(3) Internal Revenue Exemption are not required to submit a copy of the Franchise Tax Account Status from the State Comptroller’s Oice.

Page 2-7

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

B.3 PRINCIPAL INFORMATION FORM (PIF-2) (6 PAGES)

Required for any person or entity that meets the deinition of a “Principal” or “Subcontractor”

as deined below.

A separate copy of this Principal Information Form (PIF-2) must be completed in full for each Principal or Subcontractor of the Provider, before enrollment.

A Principal of the Provider is deined as follows:

All owners with a direct or indirect ownership or control interest of 5 percent or more.

All corporate oicers and directors, all limited and non-limited partners, and all shareholders of a provider entity (including a professional corporation, professional association, or limited liability company).

All managing employees or agents who exercise operational or managerial control, or who directly or indirectly manage the conduct of day-to-day operations.

All individuals, companies, irms, corporations, employees, independent contractors, entities or associations who 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.

A Subcontractor of the Provider is deined 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 iscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies

All spaces must be completed either with the correct answer or a “NA” on the questions that do not apply to the Principal or Subcontractor.

All owners that have a 5 percent or more direct or indirect ownership interest in a provider that is assigned a high-categorical risk level must submit ingerprints for enrollment or revalidation in Texas Medicaid.

he Provider or provider’s duly authorized representative must personally review each copy of this completed form and certify to the validity and completeness of the information provided by signing the Provider Agreement.

Check person or entity:

Person

Entity

If Entity, please complete the following information.

Tax ID number as shown on the W9 IRS form:

Legal name as shown on the W9 IRS form:

Company Name:

Address as shown on the W9 IRS form:

 

 

 

 

Number Street

Suite

City

State

ZIP

How is the entity organized to conduct business activities? Examples include: Sole Proprietor (Unincorporated), Professional Association, General Partnership, Limited Partnership, Limited Liability Partnership, Limited Liability Company, Corporation, Nonproit, Governmental

Do you conduct business under an assumed name?

If Yes, provide the assumed name below.

Yes No

Assumed Name:

Page 2-8

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

If you selected Person above, please complete the following information.

Last Name:

Maiden Name:

First Name/Middle Initial:

List any other alias, name, or form of your name ever used:

he following information must be completed by all Principals, Subcontractors, and Creditors. For additional names or addresses, attach pages as necessary.

Check principal or subcontractor

Principal

Subcontractor

 

 

 

 

 

 

 

 

 

Physical address:

 

 

 

 

 

Number

Street

 

Suite

City

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

Accounting/billing address:

 

 

 

 

 

Number

Street

 

Suite

City

State

ZIP

If your accounting address is diferent than your physical address, indicate your relationship to the accounting address:

Billing agent

Management company

Employer

Self

Other (explain below)

If you chose Other, please explain:

Social Security Number:

 

Federal Tax ID number:

 

 

 

 

 

 

 

 

Specialty of practice: (i.e., pediatrics, general practice, etc.)

 

Medicare intermediary: (if applicable)

 

 

 

 

 

 

 

 

Medicare provider number: (if applicable)

 

Medicare efective date: MM/DD/YYYY (if applicable)

 

 

 

 

 

 

 

 

Driver’s license number:

 

State:

Driver’s license expiration date: MM/DD/YYYY

 

 

 

 

 

 

 

 

Date of birth: MM/DD/YYYY

Gender:

Male Female

Page 2-9

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Do you have one or more professional licenses, accreditations, or certiications?

 

Yes No

If Yes, provide the following information.

 

 

 

 

 

1.

 

Professional Licensing or Certiication Board:

Licensing State:

 

 

 

 

 

 

 

 

 

 

License Accreditation Certiication Issuer:

License Accreditation Certiication Number:

 

 

 

 

 

 

 

 

 

 

Issue Date (MM/DD/YYYY):

Expiration Date (MM/DD/YYYY):

 

 

 

 

 

 

 

 

2.

 

Professional Licensing or Certiication Board:

Licensing State:

 

 

 

 

 

 

 

 

 

 

License Accreditation Certiication Issuer:

License Accreditation Certiication Number:

 

 

 

 

 

 

 

 

 

 

Issue Date (MM/DD/YYYY):

Expiration Date (MM/DD/YYYY):

 

 

 

 

 

 

 

 

3.

 

Professional Licensing or Certiication Board:

Licensing State:

 

 

 

 

 

 

 

 

 

 

License Accreditation Certiication Issuer:

License Accreditation Certiication Number:

 

 

 

 

 

 

 

 

 

 

Issue Date (MM/DD/YYYY):

Expiration Date (MM/DD/YYYY):

 

 

 

 

 

 

 

 

4.

 

Professional Licensing or Certiication Board:

Licensing State:

 

 

 

 

 

 

 

 

 

 

License Accreditation Certiication Issuer:

License Accreditation Certiication Number:

 

 

 

 

 

 

 

 

 

 

Issue Date (MM/DD/YYYY):

Expiration Date (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

Previous Physical address:

 

 

 

 

Number

Street

Suite

City

State

ZIP

 

 

 

 

 

 

 

 

 

 

Previous Accounting address:

 

 

 

 

Number

Street

Suite

City

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

Your title in the provider organization for which enrollment is being sought:

Your duties to the provider organization: (attach additional sheets if necessary)

Page 2-10

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Your role in the provider organization: Examples are Accountant, Agency, Attorney, Banker, Bookkeeper, Business, Care Giver, Consultant, Contractual, Corporate Oicer, Director, Doctor, Elected Oicial, Employee, Employer, Government Oicial , Individual (Contracted), Individual (Fiscal Agent), Limited Partner, Managing Employee, Medical Director, Non-Limited Partner, Nurse, Oicial, Owner (Direct), Owner (Indirect) Parent, Recruiter, Representative, Shareholder, Subcontractor, or Unknown: (attach additional sheets if necessary)

Efective date of your role in the provider organization: MM/DD/YYYY

Do you have a relationship with a separate provider?

Yes No

If “Yes,” explain relationship with the separate provider below:

List all TPIs, provider names, and physical locations under which you have billed or in which your were a principal. Include current and previous TPIs : (attach additional sheets if necessary)

List all Providers and medical entities that you have a contractual relationship with and, if known, the NPI/API and TPI of each provider or entity. (attach additional sheets if necessary)

1.

Name:

 

 

Social Security Number:

 

Date of birth: MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical address:

 

 

 

 

 

 

 

Number

Street

 

Suite

City

 

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal Tax ID:

 

TPI:

 

NPI/API:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Name:

 

 

Social Security Number:

 

Date of birth: MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical address:

 

 

 

 

 

 

 

Number

Street

 

Suite

City

 

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal Tax ID:

 

TPI:

 

NPI/API:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Name:

 

 

Social Security Number:

 

Date of birth: MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical address:

 

 

 

 

 

 

 

Number

Street

 

Suite

City

 

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal Tax ID:

 

TPI:

 

NPI/API:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Name:

 

 

Social Security Number:

 

Date of birth: MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical address:

 

 

 

 

 

 

 

Number

Street

 

Suite

City

 

State

ZIP

Federal Tax ID:

TPI:

NPI/API:

Page 2-11

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

“Sanction” is deined as recoupment, payment hold, imposition of penalties or damages, contract cancellations, exclusion, debarment, suspension, revocation, or any other synonymous action.

Have you ever been sanctioned (as deined above) in any state or federal program?

YES NO

If Yes, fully explain the details, including date, the state where the incident occurred, the agency taking the action, and the program afected. (attach additional sheets if necessary)

Is your professional license or certiication currently revoked, suspended or otherwise restricted?

Have you ever had your professional license or certiication revoked, suspended, or otherwise restricted? Are you currently, or have you ever been, subject to a licensing or certiication board order?

Have you voluntarily surrendered your professional license or certiication in lieu of disciplinary action?

(You may be subject to a license or certiication veriication/status check with your licensing or certiication board.)

YES NO

YES NO

YES NO

YES NO

If Yes was answered to any of these questions, fully explain the details, including date, the state where the incident occurred, name of the board or agency, and any adverse action against your license. (attach additional sheets if necessary)

Are you currently or have you ever been subject to the terms of a settlement agreement, corporate compliance agreement or corporate integrity agreement in relation to any State or Federally funded program?

Do you currently have any outstanding debt in relation to any State or Federally funded program?

YES NO

YES NO

If YES was answered to any of these questions, fully explain the details, including date, the state where the incident occurred, and name of the board or agency. (attach additional sheets if necessary)

“Convicted” means that:

(a)A judgment of conviction has been entered against an individual or entity by a Federal, State or local court, regardless of whether:

(1)here is a post-trial motion or an appeal pending, or

(2)he judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed;

(b)A Federal, State or local court has made a inding of guilt against an individual or entity;

(c)A Federal, State or local court has accepted a plea of guilty or nolo contendere by an individual or entity, or

(d)An individual or entity has entered into participation in a irst ofender, deferred adjudication or other program or arrangement where judgment of conviction has been withheld.

Are you currently charged with or have you ever been convicted of a crime (excluding

YES

NO

Class C misdemeanor traic citations)?

 

 

To answer this question, use the federal Medicaid/Medicare deinition of “Convicted” in 42 CFR. § 1001.2 as described above, and

 

 

which includes deferred adjudications and all other types of pretrial diversion programs. You may be subject to a criminal history

 

 

check.

 

 

Have you been arrested for a crime but not yet charged?

YES

NO

Is there an outstanding warrant for arrest?

YES

NO

 

 

 

If Yes, fully explain the details, including date, the state and county where the conviction occurred, the cause number(s),

 

 

and speciically what you were convicted of. (attach additional sheets if necessary)

 

 

Page 2-12

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Are you currently subject to court ordered child support payments?

YES NO

If Yes, please provide details.

Are you currently behind 30 days or more on court ordered child support payments?

YES NO

If Yes, provide details of how these past-due payment obligations will be met. (attach additional sheets if necessary)

Are you a citizen of the United States?

If No, provide the country of which you are a citizen.

YES NO

If you are not a citizen of the United States, do you have a legal right to work in the United States?

If Yes, attach a copy of your green card, visa, or other documentation demonstrating your right to reside and work in the United States.

YES NO

Page 2-13

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

SECTION C: GROUP PRACTICE

his section is only for applicants that are enrolling as a group practice.

Note: All performing providers listed here must complete a separate PIF-1 and HHSC Medicaid Provider Agreement. See the instructions for additional information.

If the applicant is enrolling as a single-specialty group or a clinic/group practice, list all performing providers that will be enrolled as part of the group.

1.

Name:

 

Date of birth: MM/DD/YYYY

Social Security Number:

Title/Degree:

 

 

 

 

 

 

 

 

 

 

 

 

 

TPI number(s):

Professional license

Professional license initial

Pharmacist certiication

Medicare

 

(only applicable for existing

number:

issue date:

issue date:

number:

 

performing providers)

 

MM/DD/YYYY

MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Name:

 

Date of birth: MM/DD/YYYY

Social Security Number:

Title/Degree:

 

 

 

 

 

 

 

 

 

 

 

 

 

TPI number(s):

Professional license

Professional license initial

Pharmacist certiication

Medicare

 

(only applicable for existing

number:

issue date:

issue date:

number:

 

performing providers)

 

MM/DD/YYYY

MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Name:

 

Date of birth: MM/DD/YYYY

Social Security Number:

Title/Degree:

 

 

 

 

 

 

 

 

 

 

 

 

 

TPI number(s):

Professional license

Professional license initial

Pharmacist certiication

Medicare

 

(only applicable for existing

number:

issue date:

issue date:

number:

 

performing providers)

 

MM/DD/YYYY

MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Name:

 

Date of birth: MM/DD/YYYY

Social Security Number:

Title/Degree:

 

 

 

 

 

 

 

 

 

 

 

 

 

TPI number(s):

Professional license

Professional license initial

Pharmacist certiication

Medicare

 

(only applicable for existing

number:

issue date:

issue date:

number:

 

performing providers)

 

MM/DD/YYYY

MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Name:

 

Date of birth: MM/DD/YYYY

Social Security Number:

Title/Degree:

 

 

 

 

 

 

 

 

 

 

 

 

 

TPI number(s):

Professional license

Professional license initial

Pharmacist certiication

Medicare

 

(only applicable for existing

number:

issue date:

issue date:

number:

 

performing providers)

 

MM/DD/YYYY

MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Name:

 

Date of birth: MM/DD/YYYY

Social Security Number:

Title/Degree:

 

 

 

 

 

 

 

 

 

 

 

 

 

TPI number(s):

Professional license

Professional license initial

Pharmacist certiication

Medicare

 

(only applicable for existing

number:

issue date:

issue date:

number:

 

performing providers)

 

MM/DD/YYYY

MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2-14

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

SECTION D: PROVIDER INFORMATION FORM (PIF-1) (6 PAGES)

Each Provider must complete this Provider Information Form (PIF-1), before enrollment. A provider is any person or legal entity that meets the deinition below.

Each Provider must also complete a Principal Information Form (PIF-2), for each person who is a Principal of the Provider (see the PIF-2 form for a complete deinition of every person who is considered to be a Principal of the Provider).

All questions on this form must be answered by or on behalf of the Provider, by ALL provider types (all spaces must be completed either with the correct answer or a “NA” on the questions that do not apply to the Provider).

All high-categorical risk level providers must submit ingerprints for enrollment or revalidation in Texas Medicaid.

he Provider or provider’s duly authorized representative must personally review this completed form and certify to the validity and completeness of the information provided by signing the HHSC Medicaid Provider Agreement or other State Health-Care Program Agreement.

“Provider” - Any person or legal entity, including a managed care organization and their subcontractors, furnishing Medicaid services under a State Health-Care Program provider agreement or contract in force with a State Health-Care Program, and who has a provider number issued by the Commission or their designee to:

1.provide medical assistance under contract or provider agreement with HHSC, DSHS or its designee; or

2.provide third party billing services under a contract or provider agreement with HHSC, DSHS or its designee.

A “hird-Party Biller” is a type of “Provider” under the above deinition and is a person, business, or entity that submits claims on behalf of an enrolled health care provider, but is not the health care provider or an employee of the health care provider. For these purposes, an employee is a person for which the health care provider completes an IRS Form W-2 showing annual income paid to the employee.

Name of Provider Enrolling: (Group/Company name or Last, First, Middle Initial)

Maiden Name:

 

 

 

 

 

 

List any other alias, name, or form of your name ever used:

National Provider Identiier (NPI): (10-digit)

 

 

 

 

 

 

Primary Taxonomy Code: (10-digit)

 

 

Secondary Taxonomy Code: (10-digit – the provider may indicate up to 15 taxonomy codes; attach additional pages if needed)

Non-Texas-enrolled Taxonomy Code: (these codes are informational and describe services the provider performs but for which the provider does not currently bill Texas Medicaid)

For additional names or addresses, attach pages as necessary.

Physical Address (where health care is rendered): Providers MUST enter the physical address where the services are rendered to clients. If the accounting, corporate, or

mailing address is entered in this physical address ield, the application may be denied.

 

 

 

Number

Street

Suite

City

State

ZIP

Accounting/Billing Address:

Number

Street

Suite

City

State

ZIP

If your accounting address is diferent than your physical address, indicate your relationship to the accounting address:

hird Party Biller

Management Company

Employer

Self

Other (explain below)

If you chose Other, please explain:

Page 2-15

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Supervising /Consulting/Referring Physician License Number and State: (if required by your licensing or certiication board:

Issue Date:

MM/DD/YYYY

Expiration Date:

MM/DD/YYYY

Social Security Number:

Federal Tax ID Number:

Specialty of Practice: (i.e., pediatrics, general practice, etc.)

Medicare Intermediary: (if applicable)

Medicare Provider Number: (if applicable)

Medicare Efective Date: MM/DD/YYYY (if applicable)

Driver’s License Number:

State:

Driver’s License Expiration Date: MM/DD/YYYY

Date of Birth: MM/DD/YYYY

Gender:

MALE FEMALE

Do you have one or more professional licenses, accreditations, or certiications?

 

YES NO

If Yes, provide the following information.

 

 

 

 

 

 

1.

 

Professional Licensing or Certiication Board:

Licensing State:

 

 

 

 

 

 

 

 

 

 

 

 

License Accreditation Certiication Issuer:

License Accreditation Certiication Number:

 

 

 

 

 

 

 

 

 

 

Issue Date: MM/DD/YYYY

Expiration Date: MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

2.

 

Professional Licensing or Certiication Board:

Licensing State:

 

 

 

 

 

 

 

 

 

 

 

 

License Accreditation Certiication Issuer:

License Accreditation Certiication Number:

 

 

 

 

 

 

 

 

 

 

Issue Date: MM/DD/YYYY

Expiration Date: MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

Page 2-16

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

3.

Professional Licensing or Certiication Board:

Licensing State:

 

 

 

 

 

 

 

 

License Accreditation Certiication Issuer:

License Accreditation Certiication Number:

 

 

 

 

 

 

 

Issue Date: MM/DD/YYYY

Expiration Date: MM/DD/YYYY

 

 

 

 

 

 

4.

Professional Licensing or Certiication Board:

Licensing State:

 

 

 

 

 

 

 

 

License Accreditation Certiication Issuer:

License Accreditation Certiication Number:

 

 

 

 

 

 

 

Issue Date: MM/DD/YYYY

Expiration Date: MM/DD/YYYY

 

 

 

 

 

 

CLIA Certiication Number: (attach a copy of the CLIA certiication, if applicable)

Hospitals providing laboratory services, and independent laboratories (including those located in physician’s oices), must answer all CLIA certiication questions. he CLIA rules and regulations are available on the CMS website at www.cms.gov.

CLIA Certiication Address: (list the address listed on the CLIA Certiicate, if applicable)

 

 

 

Number

Street

Suite

City

State

ZIP

CLIA Certiication Efective Date (if applicable):

CLIA Certiication Expiration Date (if applicable):

Previous Physical Address:

Number StreetSuiteCityState ZIP

Previous Accounting Address:

Number

Street

Suite

City

State

ZIP

Do you plan to use a hird Party Biller to submit your health-care claims?

Yes

No

If Yes, provide the following information about the billing agent.

Billing Agent Name:

Address:

Federal Tax ID Number:

Contact Person Name:

Telephone Number:

Page 2-17

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

additional sheets if necessary)

List all Providers and medical entities that you have a contractual relationship with and, if known, the NPI/API and TPI of each provider or entity. (attach

1. Name:

 

 

Social Security Number:

 

Date of Birth: MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical address:

 

 

 

 

 

Number

Street

Suite

City

State

ZIP

Federal Tax ID:

TPI:

NPI/API:

2.Name:

Social Security Number:

Date of Birth: MM/DD/YYYY

Physical Address:

Number

Street

Suite

City

State

ZIP

Federal Tax ID:

TPI:

NPI/API:

3.Name:

Social Security Number:

Date of Birth: MM/DD/YYYY

Physical Address:

Number

Street

Suite

City

State

ZIP

Federal Tax ID:

TPI:

NPI/API:

4.Name:

Social Security Number:

Date of Birth: MM/DD/YYYY

Physical Address:

Number

Street

Suite

City

State

ZIP

Federal Tax ID:

TPI:

NPI/API:

5.Name:

Social Security Number:

Date of Birth: MM/DD/YYYY

Physical Address:

Number

Street

Suite

City

State

ZIP

Federal Tax ID:

TPI:

NPI/API:

Page 2-18

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

“Sanction” is deined as recoupment, payment hold, imposition of penalties or damages, contract cancellations, exclusion, debarment, suspension, revocation, or any other synonymous action.

Have you ever been sanctioned (as deined above) in any state or federal program?

YES NO

If Yes, fully explain the details, including date, the state where the incident occurred, the agency taking the action, and the program afected. (attach additional sheets if necessary)

Is your professional license or certiication currently revoked, suspended or otherwise restricted?

Have you ever had your professional license or certiication revoked, suspended, or otherwise restricted? Are you currently, or have you ever been, subject to a licensing or certiication board order?

Have you voluntarily surrendered your professional license or certiication in lieu of disciplinary action?

(You may be subject to a license or certiication veriication/status check with your licensing or certiication board.)

YES NO

YES NO

YES NO

YES NO

If Yes was answered to any of these questions, fully explain the details, including date, the state where the incident occurred, name of the board or agency, and any adverse action against your license. (attach additional sheets if necessary)

Have you ever enrolled in or applied to any other State’s Medicaid or CHIP program?

Are you currently or have you ever been subject to the terms of a settlement agreement, corporate compliance agreement or corporate integrity agreement in relation to any State or Federally funded program?

Do you currently have any outstanding debt in relation to any State or Federally funded program?

YES NO

YES NO

YES NO

If Yes was answered to any of the questions, fully explain the details including date, and the state if applicable.

Page 2-19

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

“Convicted” means that:

(a)A judgment of conviction has been entered against an individual or entity by a Federal, State or local court, regardless of whether:

(1)here is a post-trial motion or an appeal pending, or

(2)he judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed;

(b)A Federal, State or local court has made a inding of guilt against an individual or entity;

(c)A Federal, State or local court has accepted a plea of guilty or nolo contendere by an individual or entity, or

(d)An individual or entity has entered into participation in a irst ofender, deferred adjudication or other program or arrangement where judgment of conviction has been withheld.

Are you currently charged with or have you ever been convicted of a crime (excluding

 

 

Class C misdemeanor traic citations)?

Yes

No

To answer this question, use the federal Medicaid/Medicare deinition of “Convicted” in 42 CFR. § 1001.2 as described above, and

 

 

which includes deferred adjudications and all other types of pretrial diversion programs. You may be subject to a criminal history

 

 

check.

 

 

Have you been arrested for a crime but not yet charged?

Yes

No

 

 

Is there an outstanding warrant for your arrest?

Yes

No

If Yes, fully explain the details, including date, the state and county where the conviction occurred, the cause number(s), and speciically what you were convicted of. (attach additional sheets if necessary)

Are you currently subject to court-ordered child support payments?

If Yes, provide details.

Yes No

Are you currently behind 30 days or more on court ordered child support payments?

Yes

No

 

 

 

If Yes, provide details of how these past-due payment obligations will be met. (attach additional sheets if necessary)

Are you a citizen of the United States?

If No, provide the country of which you are a citizen.

Yes No

If you are not a citizen of the United States, do you have a legal right to work in the United States?

If Yes, attach a copy of your green card, visa, or other documentation demonstrating your right to reside and work in the United States.

Yes No

FINGERPRINT CRIMINAL BACKGROUND CHECK (FCBC) FOR HIGH-CATEGORICAL RISK PROVIDERS

I acknowledge that I am required to submit proof of ingerprinting.

Page 2-20

Texas Medicaid Provider Enrollment Application

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

HHSC MEDICAID PROVIDER AGREEMENT

Name of provider enrolling:

Medicaid TPI: (if applicable)

Medicare provider ID number: (if applicable)

Physical address (where health care is rendered): Providers MUST enter the physical address where the services are rendered to clients. If the accounting, corporate, or mailing address is entered in this physical address field, the application may be denied.

NumberStreetSuiteCityStateZIP

Accounting/billing address: (if applicable)

Number

Street

Suite

City

State

ZIP

As a condition for participation as a provider under the Texas Medical Assistance Program (Medicaid), the Provider (Provider) agrees to comply with all terms and conditions of this Agreement.

I.ALL PROVIDERS

1.1Agreement and documents constituting Agreement.

he current TEXAS MEDICAID PROVIDER PROCEDURES MANUAL (Provider Manual) may be accessed via the internet at www.tmhp.com. Provider has a duty to become educated and knowledgeable with the contents and procedures contained in the Provider Manual. Provider agrees to comply with all of the requirements of the Provider Manual, as well as all state and federal laws governing or regulating Medicaid, and provider further acknowledges and agrees that the provider is responsible for ensuring that all employees and agents of the provider also comply. Provider agrees to acknowledge HHSC’s provision of enrollment processes and authority to make enrollment decisions as found in Title 1, Part 15, Chapter 352 of the Texas Administrative Code. Provider is specifically responsible for ensuring that the provider and all employees and agents of the Provider comply with the requirements of Title 1, Part 15, Chapter 371 of the Texas Administrative Code, related to waste, abuse and fraud, and provider acknowledges and agrees that the provider and its principals will be held responsible for violations of this Agreement through any acts or omissions of the provider, its employees, and its agents. For purposes of this Agreement, a principal of the provider includes all owners with a direct or indirect ownership or control interest of five percent or more, all corporate officers and directors, all limited and non-limited partners, and all shareholders of a legal entity, including a professional corporation, professional association, or limited liability company. Principals of the provider further include managing employee(s) or agents who exercise operational or managerial control or who directly or indirectly manage the conduct of day-to-day operations.

1.2State and Federal regulatory requirements.

1.2.1By signing this Agreement, Provider certifies that the provider and its principals have not been excluded, suspended, debarred, revoked or any other synonymous action from participation in any program under Title XVIII (Medicare), Title XIX (Medicaid), or under the provisions of Executive Order 12549, relating to federal contracting. Provider further certifies that the provider and its principals have also not been excluded, suspended, debarred, revoked or any other synonymous action from participation in any other state or federal health-care program. Provider must notify the Health and Human Services Commission (HHSC) or its agent within 10 business days of the time it receives notice that any action is being taken against Provider or any person defined under the provisions of Section 1128(A) or (B) of the Social Security Act (42 USC §1320a-7), which could result in exclusion from the Medicaid program. Provider agrees to fully comply at all times with the requirements of 48 CFR, Ch. 3, relating to eligibility for federal contracts and grants.

1.2.2Provider agrees to disclose information on ownership and control, information related to business transactions, and information on persons convicted of crimes in accordance with 42 CFR Part 455, Subpart B, and provide such information on request to the Texas Health and Human Services Commission (HHSC), Department of State Health Services (DSHS), Texas Attorney General’s Medicaid Fraud Control Unit, and the United States Department of Health and Human Services. Provider agrees to keep its application for participation in the Medicaid program current at all times by informing HHSC or its agent in writing of any changes to the information contained in its application, including, but not limited to, changes in ownership or control, federal tax identification number, provider licensure, certification, or accreditation, phone number, or provider business addresses. Changes due to a change of ownership or control interest must be reported to HHSC or its designee within 30 days of the change. All other changes must be reported to HHSC or its designee within 90 days of the change.

Provider agrees to disclose all convictions of Provider or Provider’s principals within ten business days of the date of conviction. For purposes of this disclosure, Provider must use the definition of “Convicted” contained in 42 CFR 1001.2, which includes all convictions, deferred adjudications, and all types of pretrial diversion programs. Send the information to the Texas Health and Human Services Commission’s Oice of Inspector General, P.O. Box 85211 – Mail Code 1361, Austin, Texas 78708. Fully explain the details, including the ofense, the date, the state and county where the conviction occurred, and the cause number(s).

1.2.3his Agreement is subject to all state and federal laws and regulations relating to fraud, abuse and waste in health care and the Medicaid program. As required by 42 CFR § 431.107, Provider agrees to create and maintain all records necessary to fully disclose the extent and medical necessity of services provided by the Provider to individuals in the Medicaid program and any information relating to payments claimed by the Provider for furnishing Medicaid services. On request, Provider also agrees to provide these records immediately and unconditionally to HHSC, HHSC’s

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agent, the Texas Attorney General’s Medicaid Fraud Control Unit, DARS, DADS, DFPS, DSHS and the United States Department of Health and Human Services. he records must be retained in the form in which they are regularly kept by the Provider for a minimum of five years from the date of service (six years for freestanding rural health clinics and ten years for hospital based rural health clinics); or, until all investigations are resolved and closed, or audit exceptions are resolved; whichever period is longest. Provider must cooperate and assist HHSC and any state or federal agency charged with the duty of identifying, investigating, sanctioning, or prosecuting suspected fraud and abuse. Provider must also allow these agencies and their agents unconditional and unrestricted access to its records and premises as required by Title 1 TAC, §371.1667. Provider understands and agrees that payment for goods and services under this Agreement is conditioned on the existence of all records required to be maintained under the Medicaid program, including all records necessary to fully disclose the extent and medical necessity of services provided, and the correctness of the claim amount paid. If provider fails to create, maintain, or produce such records in full accordance with this Agreement, provider acknowledges, agrees, and understands that the public monies paid the provider for the services are subject to 100 percent recoupment, and that the provider is ineligible for payment for the services either under this Agreement or under any legal theory of equity.

1.2.4he Texas Attorney General’s Medicaid Fraud Control Unit, the Texas Health and Human Services Commission’s Oice of Inspector General, and internal and external auditors for the state and federal government may conduct interviews of Provider employees, agents, subcontractors, and their employees, witnesses, and clients without the Provider’s representative or Provider’s legal counsel present. Provider’s employees, agents, subcontractors and their employees, witnesses, and clients must not be coerced by Provider or Provider’s representative to accept representation from or by the Provider, and Provider agrees that no retaliation will occur to a person who denies the Provider’s ofer of representation. Nothing in this Agreement limits a person’s right to counsel of his or her choice. Requests for interviews are to be complied with in the form and the manner requested. Provider will ensure by contract or other means that its agents, employees and subcontractors cooperate fully in any investigation conducted by the Texas Attorney General’s Medicaid Fraud Control Unit or the Texas Health and Human Services Commission’s Oice of Inspector General or its designee. Subcontractors include those persons and entities that provide medical or dental goods or services for which the Provider bills the Medicaid program, and those who provide billing, administrative, or management services in connection with Medicaid- covered services.

1.2.5Nondiscrimination. Provider must not exclude or deny aid, care, service, or other benefits available under Medicaid or in any other way discriminate against a person because of that person’s race, color, national origin, gender, age, disability, political or religious affiliation or belief. Provider must provide services to Medicaid clients in the same manner, by the same methods, and at the same level and quality as provided to the general public. Provider agrees to grant Medicaid recipients all discounts and promotional ofers provided to the general public. Provider agrees and understands that free services to the general public must not be billed to the Medicaid program for Medicaid recipients and discounted services to the general public must not be billed to Medicaid for a Medicaid recipient as a full price, but rather the Provider agrees to bill only the discounted amount that would be billed to the general public.

1.2.6AIDS and HIV. Provider must comply with the provisions of Texas Health and Safety Code Chapter 85, and HHSC’s rules relating to workplace and confidentiality guidelines regarding HIV and AIDS.

1.2.7Child Support. (1) he Texas Family Code §231.006 requires HHSC to withhold contract payments from any entity or individual who is at least 30 days delinquent in court-ordered child support obligations. It is the Provider’s responsibility to determine and verify that no owner, partner, or shareholder who has at least 25 percent ownership interest is delinquent in any child support obligation. (2) Under Section 231.006 of the Family Code, the vendor or applicant certifies that the individual or business entity named in the applicable contract, bid, or application is not ineligible to receive the specified grant, loan, or payment and acknowledges that this Agreement may be terminated and payment may be withheld if this certification is inaccurate. A child support obligor who is more than 30 days delinquent in paying child support or a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an ownership interest of at least 25 percent is not eligible to receive the specified grant, loan, or payment. (3) If HHSC is informed and verifies that a child support obligor who is more than 30 days delinquent is a partner, shareholder, or owner with at least a 25 percent ownership interest, it will withhold any payments due under this Agreement until it has received satisfactory evidence that the obligation has been satisfied.

1.2.8Cost Report, Audit and Inspection. Provider agrees to comply with all state and federal laws relating to the preparation and filing of cost reports, audit requirements, and inspection and monitoring of facilities, quality, utilization, and records.

1.3CLAIMS AND ENCOUNTER DATA.

1.3.1Provider agrees to submit claims for payment in accordance with billing guidelines and procedures promulgated by HHSC, or other appropriate payer, including electronic claims. Provider certifies that information submitted regarding claims or encounter data will be true, accurate, and complete, and that the Provider’s records and documents are both accessible and validate the services and the need for services billed and represented as provided. Further, Provider understands that any falsification or concealment of a material fact may be prosecuted under state and federal laws.

1.3.2Provider must submit encounter data required by HHSC or any managed care organization to document services provided, even if the Provider is paid under a capitated fee arrangement by a Health Maintenance Organization or Insurance Payment Assistance.

1.3.3All claims or encounters submitted by Provider must be for services actually rendered by Provider. Physician providers must submit claims for services rendered by another in accordance with HHSC rules regarding providers practicing under physician supervision. Claims must be submitted in the manner and in the form set forth in the Provider Manual, and within the time limits established by HHSC for submission of claims. Claims for payment or encounter data submitted by the provider to an HMO or IPA are governed by the Provider’s contract with the HMO or IPA. Provider understands and agrees that HHSC is not liable or responsible for payment for any Medicaid-covered services provided under the HMO or IPA Provider contract, or any agreement other than this Medicaid Provider Agreement.

1.3.4Federal and state law prohibits Provider from charging a client or any financially responsible relative or representative of the client for Medicaid- covered services, except where a co-payment is authorized under the Medicaid State Plan (42 CFR §447.20).

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1.3.5As a condition of eligibility for Medicaid benefits, a client assigns to HHSC all rights to recover from any third party or any other source of payment (42 CFR §433.145 and Human Resources Code §32.033). Except as provided by HHSC’s third-party recovery rules (TEXAS ADMINISTRATIVE CODE Title 1 Part 15 Chapter 354 Subchapter J), Provider agrees to accept the amounts paid under Medicaid as payment in full for all covered services (42 CFR §447.15).

1.3.6Provider has an affirmative duty to verify that claims and encounters submitted for payment are true and correct and are received by HHSC or its agent, and to implement an efective method to track submitted claims against payments made by HHSC or its agents.

1.3.7Provider has an affirmative duty to verify that payments received are for actual services rendered and medically necessary. Provider must refund any overpayments, duplicate payments and erroneous payments that are paid to Provider by Medicaid or a third party as soon as any such payment is discovered or reasonably should have been known.

1.3.8TMHP EDI and Electronic Claims Submission. Provider may subscribe to the TMHP Electronic Data Interchange (EDI) system, which allows the Provider the ability to electronically submit claims and claims appeals, verify client eligibility, and receive electronic claim status inquiries, remittance and status (R&S) reports, and transfer of funds into a provider account. Provider understands and acknowledges that independent registration is required to receive the electronic funds or electronic R&S report. Provider agrees to comply with the provisions of the Provider Manual and the TMHP EDI licensing agreement regarding the transmission and receipt of electronic claims and eligibility verification data. Provider must verify that all claims submitted to HHSC or its agent are received and accepted. Provider is responsible for tracking claims transmissions against claims payments and detecting and correcting all claims errors. If Provider contracts with third parties to provide claims and/or eligibility verification data from HHSC, the Provider remains responsible for verifying and validating all transactions and claims, and ensuring that the third party adheres to all client data confidentiality requirements.

1.3.9Reporting Waste, Abuse and Fraud. Provider agrees to inform and train all of Provider’s employees, agents, and independent contractors regarding their obligation to report waste, abuse, and fraud. Individuals with knowledge about suspected waste, abuse, or fraud in any State of Texas health and human services program must report the information to the Texas Health and Human Services Commission’s Oice of Inspector General. To report waste, abuse or fraud, go to WWW.HHS.STATE.TX.US and select “Reporting Waste, Abuse, or Fraud”. Individuals may also call the Oice of Inspector General hotline (1-800-436-6184) to report waste, abuse or fraud if they do not have access to the Internet.

II.ADVANCE DIRECTIVES – HOSPITAL AND HOME HEALTH PROVIDERS

2.1he client must be informed of their right to refuse, withhold, or have medical treatment withdrawn under the following state and federal laws:

(a)he individual’s right to self-determination in making health-care decisions;

(b)he individual’s rights under the Natural Death Act (Health and Safety Code, Chapter 166) to execute an advance written Directive to Physicians, or to make a non-written directive regarding their right to withhold or withdraw life-sustaining procedures in the event of a terminal condition;

(c)he individual’s rights under Health and Safety Code, Chapter 166, relating to written Out-of-Hospital Do-Not-Resuscitate Orders; and,

(d)he individual’s rights to execute a Durable Power of Attorney for Health Care under the Probation Code, Chapter XII, regarding their right to appoint an agent to make medical treatment decisions on their behalf in the event of incapacity.

2.2he Provider must have a policy regarding the implementation of the individual’s rights and compliance with state and federal laws.

2.3he Provider must document whether or not the individual has executed an advance directive and ensure that the document is in the individual’s medical record.

2.4he Provider cannot condition giving services or otherwise discriminate against an individual based on whether or not the client has or has not executed an advance directive.

2.5he Provider must provide written information to all adult clients on the provider’s policies concerning the client’s rights.

2.6he Provider must provide education for staf and the community regarding advance directives.

III. STATE FUND CERTIFICATION REQUIREMENT FOR PUBLIC ENTITY PROVIDERS

3.1Public providers are those that are owned or operated by a state, county, city, or other local government agency or instrumentality. Public entity providers of the following services are required to certify to HHSC the amount of state matching funds expended for eligible services according to established HHSC procedures:

(a)School health and related services (SHARS)

(b)Case management for blind and visually impaired children (BVIC)

(c)Case management for early childhood intervention (ECI)

(d)Service coordination for intellectual and developmental disabilities (IDD)

(e)Service coordination for mental health (MH)

(f)Mental health rehabilitation (MHR)

(g)Tuberculosis clinics

(h)State hospitals

IV. CLIENT RIGHTS

4.1Provider must maintain the client’s state and federal right of privacy and confidentiality to the medical and personal information contained in Provider’s records.

4.2he client must have the right to choose providers unless that right has been restricted by HHSC or by waiver of this requirement from the Centers for Medicare and Medicaid Services (CMS). he client’s acceptance of any service must be voluntary.

4.3he client must have the right to choose any qualified provider of family planning services.

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V.THIRD PARTY BILLING VENDOR PROVISIONS

5.1Provider agrees to submit notice of the initiation and termination of a contract with any person or entity for the purpose of billing Provider’s claims, unless the person is submitting claims as an employee of the Provider and the Provider is completing an IRS Form W-2 on that person. his notice must be submitted within five working days of the initiation and termination of the contract and submitted in accordance with Medicaid requirements pertaining to hird Party Billing Vendors. Provider understands that any delay in the required submittal time or failure to submit may result in delayed payments to the Provider and recoupment from the Provider for any overpayments resulting from the Providers failure to provide timely notice.

5.2Provider must have a written contract with any person or entity for the purpose of billing provider’s claims, unless the person is submitting claims as an employee of the Provider and the Provider is completing an IRS Form W-2 on that person. he contract must be signed and dated by a Principal of the Provider and the Biller. It must also be retained in the Provider’s and Biller’s files according with the Medicaid records retention policy. he contract between the Provider and Biller may contain any provisions they deem necessary, but, at a minimum, must contain the following provisions:

(a)Biller agrees they will not alter or add procedures, services, codes, or diagnoses to the billing information received from the Provider, when billing the Medicaid program.

(b)Biller understands that they may be criminally convicted and subject to recoupment of overpayments and imposed penalties for submittal of false, fraudulent, or abusive billings.

(c)Provider agrees to submit to Biller true and correct claim information that contains only those services, supplies, or equipment Provider has actually provided to recipients.

(d)Provider understands that they may be criminally convicted and subject to recoupment of overpayments and imposed penalties for submittal of false, fraudulent, or abusive billings, directly or indirectly, to the Biller or to Medicaid or its contractor.

(e)Provider and Biller agree to establish a reimbursement methodology to Biller that does not contain any type of incentive, directly or indirectly, for inappropriately inflating, in any way, claims billed to the Medicaid program.

(f)Biller agrees to enroll and be approved by the Medicaid program as a hird Party Billing Vendor prior to submitting claims to the Medicaid program on behalf of the Provider.

(g)Biller and Provider agree to notify the Medicaid program within five business days of the initiation and termination, by either party, of the contract between the Biller and the Provider.

VI. TERM AND TERMINATION

6.1If the correspondence/notice of enrollment from HHSC or its agent states a termination date, this Agreement terminates on that date with or without other advance notice of the termination date.

6.2Provider may terminate this Agreement by providing at least 30 days written notice of intent to terminate.

6.3HHSC has grounds for terminating this Agreement, including but not limited to, the circumstances listed below, and which may include the actions or circumstances involving the Provider or any person or entity with an ailiate relationship to the Provider:

(a)the exclusion from participation in Medicare, Medicaid, or any other publically funded health-care program;

(b)the loss or suspension of professional license or certiication;

(c)any failure to comply with the provisions of this Agreement or any applicable law, rule or policy of the Medicaid program;

(d)any circumstances indicating that the health or safety of clients is or may be at risk;

(e)the circumstances for termination listed in 42 C.F.R. § 455.416, as amended; and

(f)the circumstances for termination listed in 1 T.A.C. §371.1703, as amended.

he Provider will receive written notice of termination, which will include the detailed reasons for the termination. he written notice of termination will also inform the Provider its due process rights.

6.4HHSC may also cancel this Agreement for reasons, including but not limited to, the following:

(a)upon further review of the Provider’s application, at any time during the term of this Agreement, HHSC or its agent, determines Provider is ineligible to participate in the Medicaid program; and the errors or omission cannot be corrected;

(b)if the Provider has not submitted a claim to the Medicaid program for at least 24 months; and

(c)any other circumstances resulting in Provider’s ineligibility to participate in the Medicaid program.

he Provider will receive written notiication of the cancellation of the Agreement and any rights to appeal HHSC’s determination will be included.

VII. ELECTRONIC SIGNATURES

7.1Provider understands and agrees that any signature on a submitted document certiies, to the best of the provider’s knowledge, the information in the document is true, accurate, and complete. Submitted documents with electronic signatures may be accepted by mail or fax when the sender has met the national and state standards for electronic signatures set by the Health and Human Services and the Texas Uniform Electronic Transactions Act (UETA).

7.2Provider understands and agrees that both the provider and the provider’s representative whose signature is on an electronic signature method bear the responsibility for the authenticity of the information being certified to.

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VIII. COMPLIANCE PROGRAM REQUIREMENT

8.1By signing section VIII, Provider certiies that in accordance with requirement TAC 352.5(b)(11), Provider has a compliance program containing the core elements as established by the Secretary of Health and Human Services referenced in §1866(j)(8) of the Social Security Act (42 U.S.C. §1395cc(j)(8)), as applicable.

I attest that I have a compliance plan. o Yes o No

IX. INTERNAL REVIEW REQUIREMENT

9.1Provider, in accordance with TAC 352.5 (b)(1), has conducted an internal review to conirm that neither the applicant or the re-enrolling provider, nor any of its employees, owners, managing partners, or contractors (as applicable), have been excluded from participation in a program under Title XVIII, XIX, or XXI of the Social Security Act.

I attest that an internal review was conducted to confirm that neither the applicant or the re-enrolling provider nor any of its employees, owners,

managing partners, or contractors have been excluded from participation in a program under the Title XVIII, XIX, or XXI of the Social Security Act. o Yes o No

X.PRIVACY, SECURITY, AND BREACH NOTIFICATION

10.1“Conidential Information” means any communication or record (whether oral, written, electronically stored or transmitted, or in any other form) provided to or made available to the Provider electronically or through any other means that consists of or includes any or all of the following:

(a)Protected Health Information in any form including without limitation, Electronic Protected Health Information or Unsecured Protected Health Information (as defined in 45 CFR 160.103 and 45 CFR 164.402);

(b)Sensitive Personal Information (as defined in Texas Business and Commerce Code section 521.002);

(c)Federal Tax Information (as defined in IRS Publication 1075);

(d)Personally Identifiable Information (as defined in OMB Memorandum M-07-16);

(e)Social Security Administration data;

(f)All information designated as confidential under the constitution and laws of the State of Texas and of the United States, including the Texas Health & Safety Code and the Texas Public Information Act, Texas Government Code, Chapter 552.

10.2Any Conidential Information received by the Provider under this Agreement may be disclosed only in accordance with applicable law. By signing this agreement, the Provider certiies that the Provider is, and intends to remain for the term of this agreement, in compliance with all applicable state and federal laws and regulations with respect to privacy, security, and breach notiication, including without limitation the following:

(a)he relevant portions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. Chapter 7, Subchapter XI, Part C;

(b)42 CFR Part 2 and 45 CFR Parts 160 and 164;

(c)he relevant portions of he Social Security Act, 42 U.S.C. Chapter 7;

(d)he Privacy Act of 1974, as amended by the Computer Matching and Privacy Protection Act of 1988, 5 U.S.C. § 552a;

(e)Internal Revenue Code, Title 26 of the United States Code, including IRS Publication 1075;

(f)OMB Memorandum M-07-16;

(g)Texas Business and Commerce Code Chapter 521;

(h)Texas Health and Safety Code, Chapters 181 and 611;

(i)Texas Government Code, Chapter 552, as applicable; and

(j)Any other applicable law controlling the release of information created or obtained in the course of providing the services described in this Agreement.

10.3he Provider further certiies that the Provider will comply with all amendments, regulations, and guidance relating to those laws, to the extent applicable.

10.4Provider will ensure that any subcontractor of Provider who has access to HHSC Conidential Information will sign a HIPAA-compliant Business Associate Agreement with Provider and Provider will submit a copy of that Business Associate Agreement to HHSC upon request.

XI PROVIDER’S BREACH NOTICE, REPORTING AND CORRECTION REQUIREMENTS

11.1For purposes of this section:

Breach has the meaning of the term as deined in 45 C.F.R. §164.402, and as amended. Discovery/Discovered has the meaning of the terms as deined in 45 C.F.R. §164.410, and as amended.

11.2Notiication to HHSC

(a)Provider will cooperate fully with HHSC in investigating, mitigating to the extent practicable and issuing notiications directed by HHSC, for any unauthorized disclosure or suspected disclosure of HHSC Conidential Information to the extent and in the manner determined by HHSC.

(b)Provider’s obligation begins at discovery of unauthorized disclosure or suspected disclosure and continues as long as related activity continues, until all efects of the incident are mitigated to HHSC’s satisfaction (the “incident response period”).

(c)Provider will require that its employees, owners, managing partners, or contractors or subcontractors (as applicable), comply with all of the following breach notice requirements.

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11.3Breach Notice:

1.Initial Notice.

(a)For federal information, including without limitation, Federal Tax Information, Social Security Administration Data, and Medicaid Member Information, within the irst, consecutive clock hour of discovery, and for all other types of Conidential Information not more than 24 hours ater discovery, or in a timeframe otherwise approved by HHSC in writing, initially report to HHSC’s Privacy and Security Oicers via email at: privacy@HHSCC.state.tx.us and to the HHSC division responsible for this UMCC;

(b)Report all information reasonably available to Provider about the privacy or security incident; and

(c)Name, and provide contact information to HHSC for, Provider’s single point of contact who will communicate with HHSC both on and of business hours during the incident response period.

11.448-Hour Formal Notice.

No later than 48 consecutive clock hours ater discovery, or a time within which discovery reasonably should have been made by Provider, provide formal notiication to HHSC, including all reasonably available information about the incident or breach, and Provider’s investigation, including without limitation and to the extent available:

(a)he date the incident or breach occurred;

(b)he date of Provider’s and, if applicable, its employees, owners, managing partners, or contractors or subcontractors discovery;

(c)A brief description of the incident or breach; including how it occurred and who is responsible (or hypotheses, if not yet determined);

(d)A brief description of Provider’s investigation and the status of the investigation;

(e)A description of the types and amount of Conidential Information involved;

(f)Identiication of and number of all individuals reasonably believed to be afected, including irst and last name of the individual and if applicable the, legally authorized representative, last known address, age, telephone number, and email address if it is a preferred contact method, to the extent known or can be reasonably determined by Provider at that time;

(g)Provider’s initial risk assessment of the incident or breach demonstrating whether individual or other notices are required by applicable law or this DUA for HHSC approval, including an analysis of whether there is a low probability of compromise of the Conidential Information or whether any legal exceptions to notiication apply;

(h)Provider’s recommendation for HHSC’s approval as to the steps individuals and/or Provider on behalf of Individuals, should take to protect the Individuals from potential harm, including without limitation Provider’s provision of notiications, credit protection, claims monitoring, and any speciic protections for a legally authorized representative to take on behalf of an Individual with special capacity or circumstances;

(i)he steps Provider has taken to mitigate the harm or potential harm caused (including without limitation the provision of suicient resources to mitigate);

(j)he steps Provider has taken, or will take, to prevent or reduce the likelihood of recurrence;

(k)Identify, describe or estimate of the persons, workforce, subcontractor, or individuals and any law enforcement that may be involved in the incident or breach;

(l)A reasonable schedule for Provider to provide regular updates to the foregoing in the future for response to the incident or breach, but no less than every three (3) business days or as otherwise directed by HHSC, including information about risk estimations, reporting, notiication, if any, mitigation, corrective action, root cause analysis and when such activities are expected to be completed; and

(m)Any reasonably available, pertinent information, documents or reports related to an incident or breach that HHSC requests following discovery.

11.5Investigation, Response and Mitigation.

(a)Provider will immediately conduct a full and complete investigation, respond to the incident or breach, commit necessary and appropriate staf and resources to expeditiously respond, and report as required to and by HHSC for incident response purposes and for purposes of HHSC’s compliance with report and notiication requirements, to the satisfaction of HHSC.

(b)Provider will complete or participate in a risk assessment as directed by HHSC following an incident or breach, and provide the inal assessment, corrective actions and mitigations to HHSC for review and approval.

(c)Provider will fully cooperate with HHSC to respond to inquiries and/or proceedings by state and federal authorities, persons and/or incident about the incident or breach.

(d)Provider will fully cooperate with HHSC’s eforts to seek appropriate injunctive relief or otherwise prevent or curtail such incident or breach, or to recover or protect any HHSC Conidential including complying with reasonable corrective action or measures, as speciied by HHSC in a Corrective Action Plan if directed by HHSC under the UCCM.

11.6.Breach Notiication to Individuals and Reporting to Authorities.

(a)HHSC may direct Provider to provide breach notiication to individuals, regulators or third-parties, as speciied by HHSC following a breach.

(b)Provider must obtain HHSC’s prior written approval of the time, manner and content of any notiication to individuals, regulators or third- parties, or any notice required by other state or federal authorities. Notice letters will be in Provider’s name and on Provider’s letterhead, unless otherwise directed by HHSC, and will contain contact information, including the name and title of Provider’s representative, an email address and a toll-free telephone number, for the Individual to obtain additional information.

(c)Provider will provide HHSC with copies of distributed and approved communications.

(d)Provider will have the burden of demonstrating to the satisfaction of HHSC that any notiication required by HHSC was timely made. If there are delays outside of Provider’s control, Provider will provide written documentation of the reasons for the delay.

(e)If HHSC delegates notice requirements to Provider, HHSC shall, in the time and manner reasonably requested by Provider, cooperate and assist with Provider’s information requests in order to make such notiications and reports.

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XII ACKNOWLEDGEMENTS AND CERTIFICATIONS

12.1By signing below, Provider acknowledges and certiies to all of the following:

(a)Provider agrees to notify TMHP if the Provider files or is the subject of a bankruptcy petition. he Provider must provide TMHP and HHSC with notice of the bankruptcy no later than ten days ater the case is filed. TMHP and HHSC also request notice of pleadings in the case.

(b)Provider has carefully read and understands the requirements of this Agreement, and will comply.

(c)Provider has carefully reviewed all of the information submitted in connection with its application to participate in the Medicaid program, including the provider information forms (PIF-1) and principal information form (PIF-2), and provider certifies that this information is current, complete, and correct.

(d)Provider agrees to review and update any information in the application to maintain compliance with and eligibility in the Medicaid program and continued participation therein.

(e)Provider agrees to inform HHSC or its designee in writing of any changes to the information contained in the application, whether such changes occur before or ater enrollment. he written notiication must be within 30 calendar days of any changes in the information due to a change in ownership or control interests, and within 90 days of all other changes to the information previously submitted.

(f)Provider agrees and understands that HHSC or its agent may review Provider’s application any time ater the application has been accepted and for the term of this Agreement. Provider agrees and understands that upon review, HHSC or its designee may determine that the information contained therein does not meet the Medicaid program enrollment requirements and Provider may no longer be eligible to participate in the Program. Provider will have the opportunity to correct any errors or omissions as determined by HHSC or its agent. Provider agrees and understands that any errors or omissions that are not corrected or cannot be corrected will result in termination of this Agreement.

(g)Provider understands that falsifying entries, concealment of a material fact, or pertinent omissions may constitute fraud and may be prosecuted under applicable federal and state law. Fraud is a felony, which can result in fines or imprisonment.

(h)Provider understands and agrees that any falsification, omission, or misrepresentation in connection with the application for enrollment or with claims filed may result in all paid services declared as an overpayment and subject to recoupment, and may also result in other administrative sanctions that include payment hold, exclusion, debarment, termination of this Agreement, and monetary penalties.

(i)Provider agrees to abide by all Medicaid regulations, program instructions, and Title XIX of the Social Security Act. he Medicaid laws, regulations, and program instructions are available through the Medicaid contractor. Provider understands that payment of a claim by Medicaid is conditioned upon the claim and the underlying transaction complying with such laws, regulations, and program instructions (including, but not limited to, the Federal anti-kickback statute and the Stark law), and on the provider’s compliance with all applicable conditions of participation in Medicaid.

Name of Applicant: ________________________________________________________________________________________________________

Applicant’s Signature: _____________________________________________________________ Date: ___________________________________

For applicants that are entities, facilities, groups, or organizations, and an authorized representative is completing this application with authority to sign on the applicant’s behalf, the authorized representative must sign above and print their name and title where indicated below.

Representative’s Name: _____________________________________________________________________________________________________

Representative’s Position/Title: _______________________________________________________________________________________________

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HHSC Medicaid Provider Agreement

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

IRS W–9 FORM

Form W-9

(Rev. December 2014)

Department of the Treasury

Internal Revenue Service

Request for Taxpayer

Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Print or type See Specific Instructions on page 2.

1Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2Business name/disregarded entity name, if different from above

3

Check appropriate box for federal tax classification; check only one of the following seven boxes:

 

 

 

4 Exemptions (codes apply only to

 

Individual/sole proprietor or

C Corporation

S Corporation

Partnership

Trust/estate

certain entities, not individuals; see

 

instructions on page 3):

 

single-member LLC

 

 

 

 

 

 

 

 

 

 

 

 

 

Exempt payee code (if any)

 

 

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

 

 

 

Exemption from FATCA reporting

 

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for

 

 

 

 

 

the tax classification of the single-member owner.

 

 

 

 

 

code (if any)

 

 

 

 

 

 

 

 

 

 

 

Other (see instructions)

 

 

 

 

 

 

(Applies to accounts maintained outside the U.S.)

5

Address (number, street, and apt. or suite no.)

 

 

Requester’s name and address (optional)

 

 

 

 

 

 

 

 

 

 

 

6

City, state, and ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

 

 

 

 

 

 

or

Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3.I am a U.S. citizen or other U.S. person (defined below); and

4.The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of

 

U.S. person

Date

General Instructions

Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

Form 1099-INT (interest earned or paid)

Form 1099-DIV (dividends, including those from stocks or mutual funds)

Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

Form 1099-S (proceeds from real estate transactions)

Form 1099-K (merchant card and third party network transactions)

Form 1099-C (canceled debt)

Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1.Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2.Certify that you are not subject to backup withholding, or

3.Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4.Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X

Form W-9 (Rev. 12-2014)

Page 4-1

IRS W-9 Form

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

An individual who is a U.S. citizen or U.S. resident alien;

A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;

An estate (other than a foreign estate); or

A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States:

In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;

In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1.The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2.The treaty article addressing the income.

3.The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4.The type and amount of income that qualifies for the exemption from tax.

5.Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup Withholding

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1.You do not furnish your TIN to the requester,

2.You do not certify your TIN when required (see the Part II instructions on page 3 for details),

3.The IRS tells the requester that you furnished an incorrect TIN,

4.The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5.You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships above.

What is FATCA reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions

Line 1

You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account, list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9.

a.Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note. ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b.Sole proprietor or single-member LLC. Enter your individual name as

shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c.Partnership, LLC that is not a single-member LLC, C Corporation, or S Corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d.Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.

e.Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Page 4-2

IRS W-9 Form

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Form W-9 (Rev. 12-2014)

Page 3

 

 

Line 2

If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3

Check the appropriate box in line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box in line 3.

Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a partnership for U.S. federal tax purposes, check the “Limited Liability Company” box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to be taxed as a corporation, check the “Limited Liability Company” box and in the space provided enter “C” for C corporation or “S” for S corporation. If it is a single-member LLC that is a disregarded entity, do not check the “Limited Liability Company” box; instead check the first box in line 3 “Individual/sole proprietor or single-member LLC.”

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space in line 4 any code(s) that may apply to you.

Exempt payee code.

Generally, individuals (including sole proprietors) are not exempt from backup withholding.

Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.

Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.

The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment Company Act of 1940

10—A common trust fund operated by a bank under section 584(a) 11—A financial institution

12—A middleman known in the investment community as a nominee or custodian

13—A trust exempt from tax under section 664 or described in section 4947

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for . . .

THEN the payment is exempt for . . .

 

 

Interest and dividend payments

All exempt payees except

 

for 7

 

 

Broker transactions

Exempt payees 1 through 4 and 6

 

through 11 and all C corporations. S

 

corporations must not enter an exempt

 

payee code because they are exempt

 

only for sales of noncovered securities

 

acquired prior to 2012.

 

 

Barter exchange transactions and

Exempt payees 1 through 4

patronage dividends

 

 

 

Payments over $600 required to be

Generally, exempt payees

reported and direct sales over $5,0001

1 through 52

 

 

Payments made in settlement of

Exempt payees 1 through 4

payment card or third party network

 

transactions

 

 

 

1See Form 1099-MISC, Miscellaneous Income, and its instructions.

2However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.

A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)

B—The United States or any of its agencies or instrumentalities

C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)

E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)

F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state

G—A real estate investment trust

H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940

I—A common trust fund as defined in section 584(a) J—A bank as defined in section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a)(1) M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note. You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.

Line 5

Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns.

Line 6

Enter your city, state, and ZIP code.

Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on this page), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note. See the chart on page 4 for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.

Page 4-3

IRS W-9 Form

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

Form W-9 (Rev. 12-2014)

Page 4

 

 

Part II. Certification

To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, or 5 below indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code earlier.

Signature requirements. Complete the certification as indicated in items 1 through 5 below.

1.Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2.Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3.Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

4.Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5.Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the Requester

 

For this type of account:

Give name and SSN of:

 

 

 

 

1.

Individual

The individual

 

2.

Two or more individuals (joint

The actual owner of the account or,

 

account)

if combined funds, the first

 

 

individual on the account1

3.

Custodian account of a minor

The minor2

 

 

(Uniform Gift to Minors Act)

 

 

4. a. The usual revocable savings

The grantor-trustee1

 

trust (grantor is also trustee)

 

 

 

b. So-called trust account that is

The actual owner

1

 

not a legal or valid trust under

 

 

 

 

 

state law

 

 

5.

Sole proprietorship or disregarded

The owner3

 

 

entity owned by an individual

 

 

6.

Grantor trust filing under Optional

The grantor*

 

 

Form 1099 Filing Method 1 (see

 

 

 

Regulations section 1.671-4(b)(2)(i)

 

 

 

(A))

 

 

 

 

 

 

For this type of account:

Give name and EIN of:

 

 

 

 

7.

Disregarded entity not owned by an

The owner

 

 

individual

 

 

8.

A valid trust, estate, or pension trust

Legal entity4

 

9.

Corporation or LLC electing

The corporation

 

 

corporate status on Form 8832 or

 

 

 

Form 2553

 

 

10.

Association, club, religious,

The organization

 

 

charitable, educational, or other tax-

 

 

 

exempt organization

 

 

11.

Partnership or multi-member LLC

The partnership

 

12.

A broker or registered nominee

The broker or nominee

13.

Account with the Department of

The public entity

 

 

Agriculture in the name of a public

 

 

 

entity (such as a state or local

 

 

 

government, school district, or

 

 

 

prison) that receives agricultural

 

 

 

program payments

 

 

14.

Grantor trust filing under the Form

The trust

 

 

1041 Filing Method or the Optional

 

 

 

Form 1099 Filing Method 2 (see

 

 

 

Regulations section 1.671-4(b)(2)(i)

 

 

 

(B))

 

 

1List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2Circle the minor’s name and furnish the minor’s SSN.

3You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

4List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account

title.) Also see Special rules for partnerships on page 2. *Note. Grantor also must provide a Form W-9 to trustee of trust.

Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records from Identity Theft

Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

Protect your SSN,

Ensure your employer is protecting your SSN, and

Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.

Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: spam@uce.gov or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT (1-877-438-4338).

Visit IRS.gov to learn more about identity theft and how to reduce your risk.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.

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IRS W-9 Form

 

 

Rev. XXXVI

Revised 05/01/2017 | Efective 07/01/2017

FINAL CHECKLIST

Important: Only submit the completed pages of the application and any additional required forms and attachments. Do not submit the instruction pages of this application. hey are for your reference only.

1.Complete the following required forms if applicable to your provider type and entity type — All items marked are required.

rF Texas Medicaid Identiication Form (One for each group, performing provider within the group, individual, or facility included in this enrollment package)

rF Texas Medicaid Provider Enrollment Application

rF HHSC Medicaid Provider Agreement (One for each group, performing provider within the group, individual, or facility included in this enrollment package)

rF Provider Information Form (PIF-1) (One for each group, performing provider within the group, individual, or facility in this enrollment package)

rF Principal Information Form (A separate copy of this Principal Information Form (PIF-2) must be completed in full for each Principal, Subcontractor, and Creditor of the Provider, before enrollment) (performing providers

are exempt)

rF Disclosure of Ownership and Control Interest Statement Form (performing providers and SHARS providers are exempt) rF IRS W-9 Form (performing providers are exempt)

F Corporate Board of Directors Resolution Form — Must Be NOTARIZED

F Medicaid Audit Information Form

F Healthy Texas Women Certiication

F Physician Relationship Agreement for Certiied Nurse Midwives (CNMs) and Licensed Midwives (LMs)

F Texas Medicaid Surety Bond Form (DME providers and non-government-operated ambulance providers only)

2.If applicable, complete and/or submit the following optional forms.

F Electronic Funds Transfer (EFT) Notiication and copy of a voided check or signed letter from the bank. (he signed letter from the bank must be on the bank’s letterhead.)

F Texas Vaccines for Children (TVFC) Program Provider Agreement

FFor CSHCN Services Program enrollment:

CSHCN Services Program Identiication Form

Provider Agreement with the Department of State Health Services (DSHS) for Participation in the Children with Special Health Care Needs (CSHCN) Services Program

Required Information for Customized Durable Medical Equipment (DME) Providers (as applicable)

Required Information for Designation as a Team Member or Ailiated Provider of a CSHCN Services Program Comprehensive Clet/Craniofacial Team (as applicable)

Required Information for Enrollment as a CSHCN Services Program Dental Orthodontia Provider (as applicable)

Required Information for Enrollment as a CSHCN Services Program Stem Cell Transplant Facility (as applicable)

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Final Checklist

 

 

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3.Obtain signatures — hese must be original signatures. Sworn Statements must be properly notarized by a Notary Public. All items checked are required forms for all providers.

rF HHSC Medicaid Provider Agreement

rF IRS W-9 Form (performing providers are exempt)

F Corporate Board of Directors Resolution Form — Must Be NOTARIZED

F Electronic Funds Transfer (EFT) Notiication

F Texas Vaccines for Children (TVFC) Program Provider Agreement

4.Attach all required documents

FFacility Providers — Attach a copy of your permit/license.

FClinical Laboratory Providers — Attach a copy of your CLIA certiicate with approved specialty services as appropriate.

FFQHC Providers — Attach a copy of the following:

Federally Qualiied Health Center Ailiation Aidavit

Your grant award

Names and addresses of your satellite centers that have been approved by the Public Health Service

FMammography Services Providers — Attach a copy of the certiication of your mammography systems from the Bureau of Radiation Control (BRC).

FFreestanding RHC Providers — Attach a copy of your encounter rate letter from Medicaid.

FAttach a copy of your approval letter or contract if required. (Refer to the Identiication Form for provider types that require approval letter/contract.)

FProviders Incorporated In Texas — Attach a copy of the following:

Corporate Board of Directors Resolution Form

Articles or Certiication of Incorporation or Certiicate of Fact

Certiicate of Formation or Certiicate of Filing

Franchise Tax Account Status

FOut-of-State Incorporated Providers — Attach a copy of the following:

Corporate Board of Directors Resolution

Certiication of Registration or Certiicate of Authority

Franchise Tax Account Status

FOut-of-State Providers — Attach proof of meeting one of the following criteria:

A medical emergency documented by the attending physician or other provider. he client’s health is in danger if he or she is required to travel to Texas. Services are more readily available in the state where the client is located.

he customary or general practice for clients in a particular locality is to use medical resources in the other state.

All services provided to adopted children receiving adoption subsidies (these children are covered for all services, not just emergency).

he services are medically necessary and the nature of the service is such that providers for this service are limited or not readily available within the state of Texas.

he services are medically necessary services to one or more dually eligible recipients (i.e., recipients who are enrolled in both Medicare and Medicaid)

he services are provided by a pharmacy that is a distributor of a drug that is classiied by the U.S. Food and Drug Administration (FDA) as a limited distribution drug.

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he services are medically necessary and one or more of the following exceptions for good cause exist and can be documented:

Texas Medicaid enrolled providers rely on the services provided by the applicant.

Applicant maintains existing agreements as a participating provider through one or more Medicaid managed care organizations (MCO) and enrollment of the applicant leads to more cost-efective delivery of Medicaid services.

A laboratory may participate as an in-state provider, regardless of the location where any speciic service is performed or where the laboratory’s facilities are located if:

he laboratory or an entity that is a parent, subsidiary, or other ailiate of the laboratory maintains laboratory operations in Texas;

he laboratory and each entity that is a parent, subsidiary, or other ailiate of the laboratory, individually or collectively, employ at least 1,000 persons at places of employment located in this state; and

he laboratory is otherwise qualiied to provide the services under the program and is not prohibited from participating as a provider under any beneit programs administered by a health and human services agency, including HHSC, based on conduct that constitutes fraud, waste, or abuse.

FHigh-Categorical Risk Providers and heir Owners hat Have 5 Percent or More Direct Ownership Interest — Attach proof of ingerprinting for each required individual (refer to the Enrollment Instructions).

5.Include the application fee (if applicable) with the application.

Make check, money order, or cahsier’s check payable in the appropriate amount to TMHP.

Only paper checks, money orders, or cashier’s checks in the amount of the CMS-directed fee will be accepted. Cash and electronic payments cannot be accepted. he application fee is a condition for enrollment. Applications cannot be processed without the fee.

Application fee is not required and will not be accepted if the provider is enrolled in Medicare, another State’s Medicaid program, or another Texas State agency. Providers will be required to submit details and/or payment of other programs or agencies to TMHP with submission of this application.

6.Make a copy for your records.

Be sure to make a copy of all documents for your own records.

7.Mail your application and all other required documents.

Mail your application and all other required documents to the following address:

Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment

P.O. Box 200795

Austin, TX 78720-0795

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APPENDIX A: ADDITIONAL FORMS

he following forms must be attached to this application if applicable to the requested provider type:

Corporate Board of Directors Resolution

Medicaid Audit Information Form

Physician Relationship Agreement for Certiied Nurse Midwife (CNM) and Licensed Midwife (LM) Providers Electronic Funds Transfer (EFT) Notiication

Healthy Texas Women Certiication

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Appendix A: Additional Forms

 

 

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CORPORATE BOARD OF DIRECTORS RESOLUTION

THE FOLLOWING FORM IS FOR CORPORATIONS ONLY,

AS INDICATED ON THE DISCLOSURE OF OWNERSHIP, QUESTION III (D).

State Of __________________________________

County Of _________________________________

On he ____________________ Day Of __________________________________________________, 20________, at a meeting of

he Board Of Directors Of __________________________________________________, A Corporation, held in the city of

____________________________________, in________________________________ county.

With A Quorum Of he Directors Present, he Following Business Was Conducted:

It was duly moved and seconded that the following resolution be adopted:

Be it resolved that the board of directors of the above corporation do hereby authorize

________________________________________________________________________________

and his/her successors in office to negotiate, on terms and conditions that he/she may deem advisable, a contract or contracts with the Texas Health and Human Services Commission, and to execute said contract or contracts on behalf of the corporation, and further we do hereby give him/ her the power and authority to do all things necessary to implement, maintain, amend, or renew said contract.

The above resolution was passed by a majority of those present and voting in accordance with the by–laws and Articles of Incorporation.

I certify that the above constitutes a true and correct copy of a part of the minutes of a meeting of the board of directors of

________________________________________________________________________________,

held on the ________________ day of _____________________________________, 20_______.

________________________________

Signature of Secretary

Subscribed and Sworn Before Me, ____________________________________________________, a Notary Public for the County of

__________________________, on the _________ day of __________________, 20____.

Notary Stamp/Seal

 

 

Notary Public, County of

___________________________________

State of

_________________________________________________

Signature

________________________________________________

MESSAGE TO NOTARY:

COMPLETE ALL OF THE BLANKS IN THIS

NOTARY STATEMENT.

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Appendix A: Additional Forms

 

 

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MEDICAID AUDIT INFORMATION FORM

HOSPITALS, HOSPITAL-AFFILIATED AMBULATORY SURGICAL

CENTERS, HOME HEALTH, FREESTANDING PSYCHIATRIC FACILITY,

CHRONIC RENAL DISEASE, TEXAS DEPARTMENT OF STATE HEALTH SERVICES,

FEDERALLY QUALIFIED HEALTH CENTER, AND COMPREHENSIVE OUTPATIENT

REHABILITATION FACILITY

REQUIRED FORM

Audit Information Form is to be illed out by facilities such as hospitals, home health, rural health, FQHC, and renal dialysis.

Cost reports, for applicable providers, are to be iled according to Medicare regulations. Provide us with the following information:

Medicaid TPI: (to be completed by TMHP)

Facility provider name:

Current iscal year end:

Medicare intermediary: (name and address of where you send your Medicare cost report)

Phone:

Contact for cost report information: (at facility)

Phone:

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PHYSICIANS LETTER OF AGREEMENT

Important: his form is required for Certiied Nurse Midwife (CNM) and Licensed Midwife (LM) Providers.

According to Texas Health and Human Services Commission (HHSC) rules 1 TAC 354.1253 (c) and 1 TAC 354.1252 (3), certiied nurse midwife (CNM) providers and licensed midwife (LM) providers are required to inform HHSC in writing of the identity of a licensed physician or group of physicians with whom the CNM or LM has arranged for referral and consultation in the event of medical complications. For purposes of this rule, “consultation” means discussion of patient status, care, and management.

Instructions: Upon initial enrollment and upon revalidation every 5 years, the CNM or LM must complete and submit to TMHP with the Medicaid provider enrollment application the following agreement airming the CNM’s supervising physician arrangement or the LM’s referring or consulting physician arrangement. A separate agreement must be submitted for each physician with whom an arrangement is made. his agreement must be signed by the CNM or LM and the physician.

A new agreement must also be completed and submitted to TMHP when a new arrangement is made and when changes to an arrangement are made. he new agreement must be submitted to TMHP within 10 business days of a cancellation or change. his agreement must be signed by the CNM or LM and the physician or physician group representative.

Note: he physician group representative must be a physician in the group, and the license number provided must be the license number of the physician who signs the form. A non-physician cannot sign this form.

Provider type (Choose one):

Date agreement is efective with the referring/consulting/supervising

 

physician:

FCertiied nurse midwife (CNM)

FLicensed midwife (LM)

CNM or LM Name:

CNM or LM License Number:

Referring/Consulting/Supervising Physician Name:

Referring/Consulting/Supervising Physician License:

Statement of Airmation

I airm that a formal agreement has been made between the physician or physician group identiied above and the certiied nurse midwife or licensed midwife identiied above with regard to referral or consultation. All parties are in agreement that arrangements are in place to discuss the status and management of client care, and for client referral and acceptance of transfer of care if necessary.

CNM/LM Signature: _________________________________________ Date:_____________________

Physician Signature: _________________________________________ Date:_______________________

Please send the completed agreement to the following address:

TMHP

Attn: TMHP Provider Enrollment Department

PO Box 200795

Austin, TX 78720-0795

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ELECTRONIC FUNDS TRANSFER (EFT) NOTICATION (5 PAGES)

INSTRUCTIONS

Electronic Funds Transfer (EFT) is a payment method used to deposit funds directly into a provider’s bank account. hese funds can be credited to either checking or savings accounts, if the provider’s bank accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks by ensuring funds are directly deposited into a speciied account.

he following items are speciic to EFT:

Pre-notiication to your bank occurs on the weekly cycle following the completion of enrollment in EFT.

Future deposits are received electronically ater pre-notiication.

he Remittance and Status (R&S) report furnishes the details of individual credits made to the provider’s acco unt during the weekly cycle.

Speciic deposits and associated R&S reports are cross-referenced by both the provider identiiers (i.e., NPI, TPI, API) and R&S number.

EFT funds are released by TMHP to depository inancial institutions each hursday.

he availability of R&S reports is unafected by EFT and they continue to arrive in the same manner and t ime frame as currently received.

TMHP must provide the following notiication according to ACH guidelines:

Most receiving depository inancial institutions receive credit entries on the day before the efective date, and these funds are routinely made available to their depositors as of the opening of business on the efective date. Contact your inancial institution regarding posting time if funds are not available on the release date.

However, due to geographic factors, some receiving depository inancial institutions do not receive their credit entries until the morning of the efective day and the internal records of these inancial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer’s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution, who in turn should work out the best way to serve their customer’s needs.

In all cases, credits received should be posted to the customer’s account on the efective date and thus be made available to cover checks or debits that are presented for payment on the efective date.

Important: Submit the completed Electronic Funds Transfer (EFT) Notiication form with a copy of a voided check or signed letter from your bank. Call the TMHP CONTACT CENTER at 1-800-925-9126 if you need assistance.

Return this form to:

Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment

PO Box 200795

Austin, TX 78720-0795

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Electronic Funds Transfer (EFT) Notiication

By submitting a signed copy of the EFT Notiication form I agree to the following:

I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period.

I (we) agree to comply with all certiication requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsiication or concealment of a material fact may be prosecuted under federal and state laws.

I (we) will continue to maintain the conidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations.

As part of the EFT enrollment process and to comply with the Afordable Care Act CAQH CORE Rule 370, please contact your inancial institution to arrange for the delivery of the CORE-required Minimum CCD+ Reassociation Data Elements. hese data elements will allow you to easily associate your EFT payment with the appropriate ERA remittance advice. You may read more about the CAQH CORE Rule at the CAQH website: http://caqh.org/

Complete the required ields on the EFT Notiication form as follows:

Provider Information

Provider Name

Provider Address

Enter the provider’s legal name according to the Internal Revenue Service (IRS).

Enter the provider’s address including the street, city, state/ province and ZIP code/postal code.

Provider Identiiers Information

Provider Federal Tax Identiication Number (TIN) or

Enter the provider’s TIN or EIN.

Employer Identiication Number (EIN)

 

 

 

National Provider Identiier (NPI)

Enter the provider’s NPI.

 

 

Other Identiier(s)

he Billing TPI and other related TPIs (up to a total of nine) for

 

this enrollment.

 

 

Assigning Authority

Organization that issues and assigns the additional identiier

 

requested on the form, e.g., Medicare, Medicaid.

Financial Institution Information

 

 

 

Financial Institution Name

Enter the name of the provider’s inancial institution

 

 

Financial Institution Address:

Enter the provider’s inancial institution’s address including the

 

street, city, state/province and ZIP code/postal code.

Financial Institution Routing Number

Enter the 9-digit routing identiier of the inancial institution where

 

EFT payments are to be deposited.

 

 

Type of Account at Financial Institution

Enter the type of account the provider will use to receive EFT

 

payments (e.g., checking, saving).

 

 

Provider’s Account Number with Financial Institution

Enter the provider’s account number at the inancial institution

 

where EFT payments are to be deposited.

Account Number Linkage to Provider Identiier

Enter the provider’s preference for grouping (bulking) claim

 

payments.

 

 

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Appendix A: Additional Forms

 

 

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Electronic Funds Transfer (EFT) Notiication

Submission Information

Reason for Submission

Select the most appropriate reason for submission of the EFT

 

Notiication form:

 

New Enrollment (New EFT request)

 

Change Enrollment (EFT change request)

 

Cancel Enrollment (EFT cancellation request)

 

Re-enrolling Providers:

 

You must select the “Change Enrollment” box in the Reason for

 

Submission ield.

 

If you are already signed up for EFT, you can use your existing

 

EFT information to complete this form. If you don’t complete this

 

form, your EFT enrollment will be canceled. If you complete the

 

form using diferent EFT information, your EFT payments will be

 

delayed while we setup a new account.

 

 

Include with Enrollment Submission

Select which document is included with the EFT Notiication form.

 

 

Authorized Signature

 

 

 

Written Signature of Person Submitting Enrollment

Signature of an individual authorized by the provider or its agent to

 

initiate, modify or terminate an enrollment.

 

 

Submission Date

Enter the date the EFT Notiication form was signed.

 

 

Printed Name of Person Submitting Enrollment

Enter the printed name of the person signing the EFT Notiication

 

form.

Printed Title of Person Submitting Enrollment

Enter the printed title of the person signing the EFT Notiication

 

form.

 

 

Requested EFT Start/Change/Cancel Date

Enter the date on which the requested action is to begin.

 

 

Other Data Elements

he other data elements within this form will allow providers to easily associate EFT and Electronic Remittance Advice (ERA) transactions.

Refer to the Council for Afordable Quality Healthcare (CAQH) website, http://caqh.org/ for more information about CORE Rule 370 and the other data elements on the EFT Notiication form.

Page A-7

Appendix A: Additional Forms

 

 

Rev. XXXVI

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Electronic Funds Transfer (EFT) Notiication

Provider Information

Provider Name *

Doing Business As Name (DBA)

Provider Address

 

 

Street *

City *

State/Province * ZIP Code/Postal Code * Country Code

 

 

 

 

 

 

 

 

 

Provider Identiiers Information

 

 

Provider Federal Tax Identiication Number (TIN) or

 

 

Employer Identiication Number (EIN) *

 

National Provider Identiier (NPI) *

Other Identiier(s) *

Assigning Authority *

Trading Partner ID

Provider License Number

License Issuer

Provider Type

Provider Taxonomy Code

Provider Contact Information

Provider Contact Name

Title

Telephone Number

Telephone Number Extension

Email Address

Fax Number

Provider Agent Information

Provider Agent Name

Agent Address

 

 

Street

City

State/Province ZIP Code/Postal Code Country Code

Provider Agent Contact Name

Title

Telephone Number

Telephone Number Extension

Email Address

Fax Number

* Required ield

Page A-8

Appendix A: Additional Forms

 

 

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Electronic Funds Transfer (EFT) Notiication

Federal Agency Information

Federal Program Agency Name

Federal Program Agency Identiier

Federal Agency Location Code

Retail Pharmacy Information

Pharmacy Name

Chain Number

Parent Organization ID

Payment Center ID

NDCP Provider ID Number

Medicaid Provider Number

Financial Institution Information

Financial Institution Name *

Financial Institution Address

 

 

 

 

 

Street *

 

City *

State/Province *

ZIP Code/Postal Code *

 

 

 

 

 

 

 

 

 

 

 

 

Financial Institution Telephone Number

Telephone Number Extension

 

 

 

 

 

 

 

 

 

 

 

 

Financial Institution Routing Number *

 

Type of Account at Financial Institution *

 

 

 

 

 

 

 

 

 

Provider’s Account Number with Financial Institution *

Account Number Linkage to Provider Identiier *

 

 

 

 

 

 

 

Provider Tax Identiication Number (TIN): _____________________________

 

 

National Provider Identiication (NPI): _________________________________

 

 

 

 

 

 

 

 

 

 

 

 

Submission Information

 

 

 

 

 

Reason for Submission *

 

 

Include with Enrollment Submission *

 

 

 

 

 

 

 

New Enrollment

 

 

 

Voided Check

 

Change Enrollment

 

 

 

Bank Letter

 

Cancel Enrollment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorized Signature

 

 

 

 

 

Written Signature of Person Submitting Enrollment *

 

 

 

 

Printed Name of Person Submitting Enrollment *

Printed Title of Person Submitting Enrollment *

Requested EFT Start/Change/Cancel Date *

Submission Date *

* Required ield

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Appendix A: Additional Forms

 

 

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HEALTHY TEXAS WOMEN CERTICATION (3 PAGES)

HEALTHY TEXAS WOMEN CERTIFICATION

his certiication pertains to the following billing or performing provider:

Provider Name _____________________________________________________________________________

Federal Tax ID Number_______________________________________________________________________

NPI Number _______________________________________________________________________________

Provider’s primary billing address:

Street Address ______________________________________________________________________________

Street Address City/State/Zip Code ______________________________________________________________

Telephone Number __________________________________________________________________________

Provider’s primary physical address:

Street Address ______________________________________________________________________________

Street Address City/State/Zip Code ______________________________________________________________

Telephone Number __________________________________________________________________________

DEFINITIONS

For the purposes of this certiication, the following terms are deined as follows:

he term “ailiate” means:

(A)An individual or entity that has a legal relationship with another entity, which relationship is created or governed by at least one written instrument that demonstrates:

(i)common ownership, management, or control;

(ii)a franchise; or

(iii)the granting or extension of a license or other agreement that authorizes the ailiate to use the other entity’s brand name, trademark, service mark, or other registered identiication mark.

he “written instruments” referenced above may include a certiicate of formation, a franchise agreement, standards of ailiation, bylaws, or a license, but do not include agreements related to a physician’s participation in a physician group practice, such as a hospital group agreement, staing agreement, management agreement, or collaborative practice agreement.

he term “promote” means advancing, furthering, advocating, or popularizing elective abortion by, for example:

(1)taking airmative action to secure elective abortion services for a Healthy Texas Women (HTW) client (such as making an appointment, obtaining consent for the elective abortion, arranging for transportation, negotiating a reduction in an elective abortion provider fee, or arranging or scheduling an elective abortion procedure); however, the term does not include providing upon the patient’s request neutral, factual information and nondirective counseling, including the name, address, telephone number, and other relevant information about a provider;

(2)furnishing or displaying to an HTW client information that publicizes or advertises an elective abortion service or provider; or

(3)using, displaying, or operating under a brand name, trademark, service mark, or registered identiication mark of an

organization that performs or promotes elective abortions.

My name is _____________________________________. I am the provider or, if the provider is an organization,

I am the provider’s (title or position) _______________________________. I am of sound mind, capable of mak-

ing this certification, and I am personally acquainted with the facts stated here. If I am representing an organizational provider, I am authorized to make this certification on the provider’s behalf.

Throughout the remainder of this document, the word “I” will represent the individual provider that is completing this form or the organizational provider on whose behalf the form is being completed. If this form is being completed on behalf of an organizational provider, the word “I” is inclusive of the organization’s owners, officers, employees, and volunteers, or any combination of these.

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Appendix A: Additional Forms

 

 

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I understand that, under Human Resources Code, Section 32.024(c-1) and relating program rules in the Texas Administrative Code, I am not qualiied to participate in the HTW program or to bill the program for services if I perform or promote elective abortions, or if I am an afiliate of an entity that performs or promotes elective abortions.

By checking the boxes under each statement below, I afirm that each of the following statements is true. I understand that my failure to mark each of the statements will be regarded as my representation that the statement is false:

1. I do not perform or promote elective abortions outside the scope of HTW.

r I afirm that this statement is true and correct.

2. I am not an afiliate of an entity that performs or promotes elective abortions.

r I afirm that this statement is true and correct.

3.In offering or performing an HTW service, I do not promote elective abortions within the scope of HTW.

r I afirm that this statement is true and correct.

4.In offering or performing an HTW service, I maintain physical and inancial separation between my HTW activities and any elective abortion-performing or abortion-promoting activity, In particular:

a.All HTW services are physically separated from any elective abortion activities, no matter what entity is responsible for the activities;

b.The governing board or other body that controls me has no board members who are also members of the governing board of an entity that performs or promotes elective abortions;

c.None of the funds that I receive for performing HTW services are used to directly or indirectly support the performance or promotion of elective abortions by an afiliate, and my accounting records conirm this;

d.At my location and in my public electronic communications, I do not display any signs or materials that promote elective abortion.

r I afirm that this statement is true and correct.

5.I do not use, display, or operate under a brand name, trademark, service mark, or registered identiication mark of an organization that performs or promotes elective abortions.

r I afirm that this statement is true and correct.

In addition, I understand and acknowledge that:

If I fail to complete and submit this certiication, I will be disqualiied from the HTW program and the Texas Health and Human Services Commission (HHSC) or its designee (henceforth, “HHSC”) will deny any claims I submit for HTW services.

If, after I submit this signed certiication, I perform, agree to perform, or promote elective abortions, or I ailiate or agree to ailiate with an entity that performs or promotes elective abortions, I will notify HHSC at least 30 calendar days before I perform or promote an elective abortion or ailiate with an entity that does so. If I fail to notify HHSC as required, I will be disqualiied from the HTW program and HHSC will deny any claims I submit for HTW services.

If, while participating in the HTW program, I or any of my organization’s subcontractors perform or promote an elective abortion, I will be disqualiied from the HTW program, including any HTW contracts, and HHSC will deny any claims I submit for HTW services.

If I submit this certiication and agree to its terms, but HHSC determines that I am in fact ineligible to participate in the HTW program, HHSC may place a payment hold on claims submitted by me or my organization for HTW services until HHSC can make a inal determination regarding my eligibility.

If HHSC determines that I am ineligible to receive funds under HTW:

a)HHSC may recoup HTW funds paid on claims that I have incurred since the date the provider became ineligible;

b)HHSC will deny all HTW claims that I have submitted since the date of ineligibility; and

c)I will remain ineligible to participate in the HTW program until I comply with Texas Human Resources Code Section 32.024(c-1) and relating program rules in the Texas Administrative Code.

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If I knowingly make a false statement or misrepresentation on this certiication, HHSC may consider me to have committed fraud or tampered with a government record under the laws of Texas, and I may be excluded from participation in the HTW program.

I also understand that, to enable HHSC to verify my or my organization’s eligibility to participate in the HTW program, I must complete and return this certiication form to HHSC at the following address:

Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment

PO Box 200795

Austin, TX 78720-0795

If statements 1 – 5 are all marked “true,” the effective date of the Certiication spans from the date of form completion through the end of the Certiication year.

Effective Date of Certiication ________________ through 12/31/________________

NOTE: Each provider must complete a new certification and mail it to TMHP by the end of each calendar year.

If any of statements 1 – 5 are not true, you must request an immediate termination of your Healthy Texas Women Certiication:

r Terminate Healthy Texas Women Certiication

Signature: ______________________________________________________________________________________

Printed Name: ___________________________________________________________________________________

Title: __________________________________________________________________________________________

Date: __________________________________________________________________________________________

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APPENDIX B: USEFUL INFORMATION - PLEASE READ

FREQUENTLY ASKED QUESTIONS

Q.How long does it take to process an enrollment application?

A.It takes up to 60 days to process the enrollment application once TMHP has received all of the information that is necessary to process it. It may take longer in special circumstances.

Q.Can I submit a temporary license?

A.TMHP only accepts temporary licenses from physicians and physician assistants.

Q.Do I have to notify TMHP when I receive my full license or when I update my license?

A.Yes. Providers are also required to submit to TMHP, within 10 days of occurrence, notice that the provider’s license or certiication has been partially or completely suspended, revoked, or retired. Not abiding by this license and certiication update requirement may impact a provider’s qualiication to continued participation in Texas Medicaid.

Q.Should I send my application by regular or certiied mail, or should I send it through an express mail service?

A.Do not send certiied mail to TMHP. You can send your application by regular mail, but TMHP recommends using an express service, like FedEx or UPS, so that you have a tracking number, a delivery receipt, and a guarantee of quick delivery. Send express mail to our physical address:

TMHP-Provider Enrollment

12357B Riata Trace Parkway

Austin, TX 78727

Q.How will I receive my new Texas Provider Identiier (TPI)?

A.Notiication letters are printed the business day ater an application is processed. Notiications are mailed to the physical address listed on the application. New providers will also receive a welcome packet that includes orientation information and other important documents.

Q.Does TMHP supply claim forms?

A.TMHP does not supply CMS-1500, Dental ADA, and UB-04 claim forms. You can buy the forms at any medical oice supply store. You can submit claims online for free using TexMedConnect.

Q.Should I wait to submit claims until I receive a TPI?

A.No. Please refer to “Claims Filing and Filing Deadline Information” in this section for more information about claims iling deadlines.

Q.As a Medicaid provider, how long do I have to retain records about the services I render?

A.You must retain records for a minimum of ive years from the date of service or until all audit questions, appeal hearings, investigations, and court cases have been resolved. Freestanding rural health clinics (RHCs) must retain records for six years. Hospital-based RHCs must retain records for 10 years. he records retention requirements do not afect any time limits for pursuing administrative, civil, or criminal claims.

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Q.How do I update my address, phone number, and other information?

A.You can update your information through your provider portal account on www.tmhp.com. Providers can only update some of their information online. All other information must be updated using the Provider Information Change Form. Providers can update the following information online:

Address, telephone numbers, and oice hours

Languages spoken

Additional sites where services are provided

Accepting new patients

Additional services ofered

Client age or gender limitations

Counties served

Medicaid waiver programs

Q.How long is my enrollment active?

A.All providers are enrolled under a limited enrollment as regulated by 42 CFR §455.414, and Title 1 Texas Administrative Code (TAC) §352.5, and §352.9. Providers are required to revalidate their enrollment at least every 3 to 5 years.

Providers must notify TMHP of any changes by submitting the Provider Information Change (PIC) Form which is available on the Forms page of the TMHP website at www.tmhp.com.

CLAIMS FILING AND FILING DEADLINE INFORMATION

As a potential new provider to Texas Medicaid, you must abide by the applicable claims iling procedures and deadlines as outlined in the current Texas Medicaid Provider Procedures Manual while your Texas Medicaid Provider Enrollment Application is in review by TMHP and HHSC. his is particularly important if you render Medicaid services to clients before you receive your welcome letter with your assigned provider identiier.

here is no guarantee that your application will be approved for processing or that you will be assigned a Texas Provider Identiier (TPI). If you decide to provide services to a Medicaid client before your application has been approved, you do so with the understanding that, if your application is denied, Texas Medicaid will not pay the claims and that the law also prohibits you from billing the Medicaid client for the services that you provided.

If you render services to Medicaid clients before you receive your TPI, you must follow the claims iling procedures and meet the iling deadlines that are speciied in the most current Texas Medicaid Provider Procedures Manual.

All claims for services rendered to Medicaid clients who do not have Medicare beneits are subject to a iling deadline from date of service of:

95 days of the date of service on the claim

365 days for OUT-OF-STATE providers or from the discharge date for inpatient claims

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Providers who render services to a Medicaid client before they complete the enrollment process and receive a TPI must submit claims within the following deadlines:

Newly enrolled providers:

TMHP must receive claims that were submitted by instate providers and providers located within 50 miles of the Texas state border within 95 days of the date on which the new provider identiier was issued.

TMHP must receive the claims within 365 days of the date of service (DOS) (i.e., the date on which the service was provided or performed).

Newly enrolled clients:

TMHP must receive the claims within 95 days of the date on which the client’s eligibility was added to the TMHP eligibility ile (i.e., the “add date”).

TMHP must receive the claims within 365 days of the DOS for professional or outpatient claims or within 365 days of the discharge date for inpatient claims.

Clients with retroactive eligibility:

TMHP must receive the claims within 95 days of the date on which the client’s eligibility was added to the TMHP eligibility ile (i.e., the “add date”).

TMHP must receive the claims within 365 days of the DOS for professional or outpatient claims or within 365 days of the discharge date for inpatient claims.

Clients with dual Medicare and Medicaid eligibility:

When the rendered service is a beneit of Medicare and Medicaid, the claim must be submitted to Medicare irst. TMHP must receive the claim for Medicaid’s portion of the payment within 95 days of the date of the Medicare disposition.

When a client is only eligible for Medicare Part B, the inpatient hospital claim is sent directly to TMHP. TMHP must receive the inpatient claim within 95 days of the date of discharge.

Note: TMHP only processes one client per Medicare RA. For multiple clients, submit one copy per client.

he Texas Administrative Code (TAC), Code of Federal Regulations, and Texas Health and Human Services Commission (HHSC) established these deadlines.

herefore, providers must submit all claims for services that have been provided to Medicaid clients to the following address within the 95-day iling deadline.

Texas Medicaid & Healthcare Partnership

PO Box 200555

Austin, TX 78720-0555

Providers with a pending application should submit any claims that are nearing the 365-day deadline from the date of service. Claims will be rejected by TMHP until a provider identiier is issued. Providers can use the TMHP rejection report as proof of meeting the 365-day deadline and submit an appeal. Procedures for appealing denied or rejected claims are included on the Remittance and Status (R&S) report that is available for download at www.tmhp.com and in the claims iling section of the Texas Medicaid Provider Procedures Manual.

LIMITED (“LOCKIN”) INFORMATION

Clients are placed in the Limited Program if, on review by HHSC and the Oice of Inspector General (OIG), their use of Medicaid services shows duplicative, excessive, contraindicated, or conlicting health care and/or drugs; or if the review indicates abuse, misuse, or fraudulent actions related to Medicaid beneits and services. Clients qualifying for limited primary care provider status are required to choose a primary care provider. he provider can be a doctor, clinic, or nurse practitioner in the Medicaid program. If a limited candidate does not choose an appropriate care provider, one

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is chosen for the client by HHSC / OIG ater obtaining an agreement from the provider. he provider is responsible for determining appropriate medical services and the frequency of such services. A referral by the primary care provider is required if the client is treated by other providers.

CHANGE OF OWNERSHIP

Under procedures set forth by the Centers for Medicare and Medicaid Services (CMS) and HHSC, a change of ownership of a facility does not terminate Medicare eligibility. herefore, Medicaid participation may be continued provided that the new owners comply with the following requirements:

1.Obtain recertiication as a Title XVIII (Medicare) facility under the new ownership.

2.Complete new Medicaid provider enrollment packet.

3.Provide TMHP with copy of the Contract of Sale (speciically, a signed agreement that includes the identiication of previous and current owners).

4.Give a listing of ALL provider identiiers afected by the change of ownership.

5.Complete and submit the CHOW Questionnaire and Statement.

WRITTEN COMMUNICATION

Enrollment Applications:

Texas Medicaid & Healthcare Partnership

Attn: Provider Enrollment

PO Box 200795

Austin, TX 78720-0795

Claims:

Texas Medicaid & Healthcare Partnership

PO Box 200555

Austin, TX 78720-0555

TELEPHONE COMMUNICATION

 

CCP Provider Customer Service

1-800-846-7470

TMHP Contact Center

1-800-925-9126

TMHP EDI Help Desk

1-888-863-3638

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Appendix B: Useful Information

 

 

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