Provider Alert! UPDATE: Provider Enrollment and Management System (PEMS) Provider GuidanceTexas Children's Health Plan
Date: February 10, 2023
Attention: All Providers
National Provider Identifier (NPI) Master Provider file effective date: March 1, 2023
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.
Important provider notice: As a reminder, the Provider Enrollment and Management System (PEMS) is the required Texas Medicaid & Healthcare Partnership (TMHP) program which is the single tool for provider enrollment, reenrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information) for Texas Medicaid.
Accordingly, as an MCO, TCHP will contract, credential and pay only those providers who are properly enrolled with TMHP and whose information is received in the official PEMS file from TMHP. In addition, it is important that every provider be enrolled at each location where they see patients. This is to help ensure claims process correctly.
For your convenience we have included information on PEMS enrollment, provider requirements, and retro-active billing allowances at the end of this Provider Alert.
How PEMS is accessed: PEMS is accessed through My Account available here,https://secure.tmhp.com/MyAccount/default.aspx. PEMS access is connected to the National Provider Identifier (NPI) or Atypical Provider Identifier (API) associated with the TMHP user account. Providers should 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 basis each enrollment application on the applying provider’s NPI or API.
- Providers who would like to enroll in Texas healthcare programs must do so under one of two categories, individual or organization, determined by their NPI or API.
More information on National Provider Identifier:
- Individual providers, performing providers, and sole proprietors will enroll in PEMS with an NPI type of Individual.
- Facility and group healthcare 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).
More information on Atypical Provider Identifier:
- Providers or individuals who do not provide healthcare 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.
Providers can view and confirm their revalidation date and enrollment information in PEMS on this 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
Providers revalidating an existing enrollment should continue to submit claims to meet their timely filing requirements.
For provider enrollment help, visit this site https://www.tmhp.com/topics/provider-enrollment/provider-enrollment-help.
Provider effective dates: Prior to the PEMS implementation, the provider billing effective date could be the Medicare enrollment effective date, the provider license date, or the application completion date (retroactive billing date).
With PEMS implementation, new and reenrolled provider agreement effective dates were upon signature of the agreements and required all screenings to be completed. After further review, HHSC, in collaboration with the Office of Inspector General (OIG) made the decision to allow retrospective billing effective dates in certain circumstances, as outlined in the table below.
Retroactive Billing Allowances Table
|Applies To||Retroactive Billing Allowed?||Allowance||Criteria|
|Medicare Enrolled Providers with same Risk Category as Medicaid||Yes||The later of either the: · Medicare Certification Date · License Effective Date · 1 Year||The following information must match between Medicaid and Medicare: · Name (Individual or Entity) · SSN (Last 4) or Tax ID Number · Owners (All 5% +) · Practice Location · NPI · Risk Category|
|Medicare Enrolled Providers with Higher Risk Category in Medicaid||No||Billing allowed only after the OIG completes all federally required screenings and recommends enrollment approval.||Elevated Medicaid Risk Categories Occur When: · Medicaid overpayment over $1,500 not currently under appeal or part of a payment arrangement. · Exclusion or Credible Allegation of Fraud within the past 10 · Moratorium lifted in the past six months.|
|Medicaid-Only Providers||Based on Risk level||Moderate and High risk: Billing allowed only after the OIG completes all federally required screenings and recommends enrollment approval. Limited risk: Billing allowed back to provider application date||Provider isn’t enrolled in Medicare; nothing to leverage. Limiting risk to state based on provider risk level.|
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