Enrolling with Texas Medicaid as a practice. No plan contracts until the state approves.

A Texas practice enrolls in Texas Medicaid through PEMS, the online enrollment system run by the Texas Medicaid & Healthcare Partnership for the Health and Human Services Commission. The practice enrolls as an organization, and each clinician enrolls as a performing provider under it. No Medicaid managed care plan can contract with or credential a clinician until that enrollment is approved.^{A, B}

Who files what.

PEMS sorts every application by the type of NPI behind it. Individual clinicians, performing providers and sole proprietors enroll with an individual NPI. Groups and facilities enroll with an organization NPI, whatever their size.^A

A group enrollment belongs to the legal entity: the partnership, corporation, limited liability company or professional association. It sits under that entity's name and tax identification number. Each clinician who treats patients for it enrolls as a performing provider under the group's tax ID, and payment goes to the group. TMHP encourages groups to file those performing provider applications through a group-initiated request, which is how we file them.^A

The order we file in.

1. Match the NPI record and the taxonomy.

Every application in PEMS is built on an NPI from NPPES, the national register CMS keeps.^C During enrollment the practice picks a primary taxonomy code for its provider type from the codes Texas approves, and that code has to match what the NPPES record attests.^A An old taxonomy is one of the first things we check.

2. Settle Medicare where it is required.

Certain provider types must be enrolled in Medicare before Texas Medicaid will enroll them. With the commission's approval, that prerequisite can be waived for practices that will never serve Medicare-eligible patients, such as pediatrics or obstetrics and gynecology.^A

3. File the organization and each performing provider in PEMS.

One online application covers every program the practice enrolls in, with one revalidation date. The practice e-signs the commission's Medicaid provider agreement, and by signing it certifies that everything in the application is complete and correct. False or incomplete information is treated as a program violation.^A We assemble the file before it goes in.

4. Expect screening by risk level.

Every applicant is screened by risk category at enrollment and again at each revalidation. Institutional providers pay an application fee unless one was already paid to Medicare or another state's Medicaid program; individual physicians and other practitioners do not.^{A, D} Moderate and high risk bring a site visit, and high risk brings fingerprints.^D

5. Contract and credential with each plan.

Every Medicaid managed care plan in Texas requires the state enrollment first. Each plan then has its own contract and its own credentialing application.^{B, E} Texas Medicaid's managed care organizations all use one credentialing verification organization, contracted through the Texas Association of Health Plans, so a clinician's verification runs through one place even when the contracts do not.^B Enrollment with the state does not guarantee any plan will contract.

What sets the timing.

The enrollment's effective date aligns with its approval date.^A Billing Texas Medicaid under a new clinician starts from approval, not from the day the application went in, so the time a file spends waiting is time a new clinician's visits cannot be billed to Texas Medicaid under their own enrollment.

What moves approval is the file itself. When an application is incomplete, TMHP gives the practice a set number of business days to supply what is missing. Miss that window and TMHP ends the enrollment, and the practice starts a new application. Provider types that need extra state approval take longer.^A Plan contracting starts only after that.

What trips practices up.

A clinician is enrolled the wrong way. Some provider types must enroll as individuals. When one of those clinicians is an employee and the employer is paid, they do not enroll as a performing provider; they enroll as an individual provider under the employer's tax ID.^A

A correction request sits unanswered. The window to fix an incomplete application is fixed, and when it closes the work starts over.^A We answer each request as it arrives.

Revalidation slips. A practice that misses its revalidation due date, and its short grace period, is disenrolled from every Texas state health care program, managed care plans included. Claims and prior authorizations are denied until it reenrolls.^A

An ordering or referring clinician never enrolls. Clinicians in a Medicaid plan's network who order or refer services must be enrolled, even when they never bill.^A

How we run it.

We check each NPI and taxonomy, settle the Medicare question, build the organization and performing provider files in PEMS, and answer every correction request inside its window. Then we take the file to the plans your patients carry. We track every application to an effective date, at the printed price for each one. If we run your billing, the first Texas Medicaid claims go out under that date and we follow each one to payment.

Questions practices ask.