Provider Alert! Provider Enrollment and Management System (PEMS) Provider Guidance

Date: July 7, 2022

Attention: All Providers

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated with the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

TCHP will apply updates and reprocess impacted claims as soon as possible. However, please allow up to sixty (60) business days for reprocessing. Providers are not required to appeal claims unless denied for other reasons.

Call to action: Texas Children’s Health Plan (TCHP) would like to offer guidance regarding the Provider Enrollment and Management System (PEMS). As a reminder, PEMS is a newly required Texas Medicaid & Healthcare Partnership (TMHP) program that went live December 13, 2022 as the single tool for provider enrollment, reenrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information).
Resource: https://www.tmhp.com/topics/provider-enrollment

How this impacts providers: TCHP will contract, credential and pay only those providers that we receive in the official file from the State after they have successfully enrolled in PEMS. In addition, every provider must be enrolled at each location where they see patients. This is help to ensure providers are properly contracted with TCHP and their claims process correctly.

Next steps for providers: PEMS is accessed through My Account, https://secure.tmhp.com/MyAccount/default.aspx. PEMS access is tied to the National Provider Identifier (NPI) or Atypical Provider Identifier (API) associated with the TMHP user account. Ensure that the NPI has all the current and correct information. After a TMHP user account is created, follow these best practices for account management:

• Assign at least two administrators.
• Update user permissions as staff changes occur.
• Look for reminders for upcoming enrollment tasks on the Message Dashboard.

More information on provider enrollment identification:

• PEMS bases each enrollment application on the applying provider’s NPI or API.
• Providers who would like to enroll in Texas health-care programs must do so under one of two categories, individual or organization, determined by their NPI or API.

National Provider Identifier:

• Individual providers, performing providers, and sole proprietors will enroll in PEMS with an NPI type

of Individual.

• Facility and group health-care providers who have a single employee or thousands of employees will enroll in PEMS with an NPI type of Organization.
• NPIs are obtained from the National Plan and Provider Enumeration System (NPPES).

Atypical Provider Identifier:

• Providers or individuals who do not provide health-care services and are not required to have NPIs may have been issued Atypical Provider Identifiers (APIs). These providers should use their APIs for enrollment purposes.

Texas Medicaid and Other Programs and Services Enrollment Types

The affected enrollment types are:

• Acute Care Services
• Comprehensive Care Program (CCP)
• Texas Health Steps Dental
• Texas Health Steps Medical
• Healthy Texas Women (HTW)
• Case Management
• Texas Health and Human Services Commission (HHSC) Long-term Care (LTC)
• Managed Care Organizations – Long-Term Services and Supports (MCO-LTSS)
• Pharmacy Services
• Medical Transportation Program (MTP)
• Kidney Health Care (KHC)
• Children with Special Health Care Needs (CSHCN) Services Program
• CSHCN Family Support Services (FSS)
• Children’s Health Insurance Program (CHIP)

Provider Requirements

Providers can view and confirm their revalidation date and enrollment information in PEMS on this site https://www.tmhp.com/topics/provider-enrollment/pems/npi-type-and-program-selection.
Here is the link to the overall enrollment site, https://www.tmhp.com/topics/provider-enrollment/pems/start-application.
To reduce application time, we encourage providers to have the following information available:

• First and last name
• Organization name
• Social Security number
• Date of birth
• Employer’s Tax Identification Number and legal name
• Licenses or certifications, if applicable
• Identification for the provider and any person who meets the definition of owner, creditor, principal, subcontractor, or managing employee
• Documentation related to disclosures, if needed
• Additional documentation required for program participation

Providers revalidating an existing enrollment should continue to submit claims to meet their timely filing requirements.

Resources:

• For provider enrollment help, visit this site https://www.tmhp.com/topics/provider-enrollment/provider-enrollment-help.
• Texas Medicaid Provider Procedures Manual, Provider enrollment and Responsibilities,
  https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2022/2022-06-june/1_01_Provider_Enrollment.pdf

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.