Section 2: Medicaid Provider Enrollment (2024)

Objectives

List the four types of Medicaid provider enrollment.

Who May Enroll?

Those who may enroll as Medicaid providers include:

Physicians (MD, DO).
Dentists.
Physician Assistants.
Advanced Practice Registered Nurses.
Rural health clinics.
Federally qualified health centers.

To be eligible for Texas Medicaid reimbursem*nt, a provider of medical services must:

Meet all applicable eligibility criteria, which include maintaining a valid, current license or certification.
Be approved by HHSC for enrollment.
Obtain a 10-digit National Provider Identifier (NPI) from the National Plan and Provider Enumeration System (NPPES).
File with TMHP the required Texas Medicaid Provider Enrollment Application, ensuring that the application is correct, complete, and includes all required attachments and additional information.
Meet all applicable criteria for eligibility to enroll.
Provide any additional information requested by TMHP, HHSC, or the HHSC Office of Inspector General in connection with the processing of the application.
Be approved by HHSC for enrollment and enter into a written provider agreement with HHSC.

Providers can enroll in Medicaid as an individual, group, performing provider, or facility. This chart details the four types of enrollment.

Types of Medicaid Provider Enrollment
Individual	Group	Performing Provider	Facility
Applies to an individual health-care professional who is licensed or certified in Texas, and who is seeking enrollment under the name, and social security or tax identification number of the individual. An individual may also enroll as an employee, using the tax identification number of the employer. Certain provider types must enroll as individuals, including dieticians, occupational therapists, and speech therapists.	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 certified or licensed in Texas. Enrollment is under the name and tax identification number of the legal entity. For any group enrollment application, there must also be at least one enrolling performing provider.	Applies to an individual health-care professional who is licensed or certified in Texas, and who is seeking enrollment under a group. Enrollment is under the tax identification number of the group, and payment is made to the group. If a health-care professional is required to enroll as an individual, 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 identification number of their employer.	Applies to situations in which licensure or certification applies to the entity. Although individuals working for or with the entity may be licensed or certified in their individual capacity, the enrollment is based on the licensure or certification of the entity. Facility enrollment does not require enrollment of performing providers.

Providers must submit a separate Texas Medicaid Provider Enrollment Application for each enrollment type requested. For example, a physician already enrolled as an individual who wishes to bill for services provided in connection with a group must submit a separate enrollment application and be approved as a performing provider with the group.

As a potential new provider to Texas Medicaid, you must follow certain claims filing procedures while completing the enrollment process. This is particularly important if you render Medicaid services to clients before you are enrolled.

There is no guarantee an application will be approved for processing or that a Medicaid Texas Provider Identifier (TPI) will be assigned. If a provider makes the decision to provide services to a Medicaid client before approval of the application, it is done with the understanding that, if the application is denied, claims will not be payable by Texas Medicaid. The law also prohibits billing the Medicaid client for such services rendered.

After receipt of all information necessary to process the application, the entire application process can take up to 45 days. This may be extended in special circ*mstances. Upon approval of the application for enrollment, completion of a written provider agreement, the provider will receive a TIN.

Providers may apply for enrollment in Medicaid online on the Texas Medicaid & Healthcare Partnership website or download an application form.

Click here to see the application form, which also includes terms, conditions, and responsibilities for Medicaid providers, FAQs, and other information. Click here to find contact information for your local Recruitment and Retention provider relations Representative.

The Texas Medicaid & Healthcare Partnership Contact Center at 800-925-9126, Option 2, offers assistance with completing the application.

Once enrolled in Medicaid, provider can enroll in Texas Health Steps. The application form can be downloaded an application form from the Texas Medicaid & Healthcare Partnership website.

Click here to see the Texas Health Steps application form, which also includes all prerequisites for Texas Health Steps providers.

Additional information on provider enrollment and responsibilities is available in Section 1 of the 2010 Texas Medicaid Provider Procedures Manual. The manual can be obtained in html and pdf formats on the Texas Medicaid & Healthcare Partnership website.

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