Credentialing in Texas – Medicaid (TMHP/PEMS)
Credentialing in Texas - Medicaid (TMHP/PEMS)
Providers must enroll through the Texas Medicaid & Healthcare Partnership (TMHP) using its Provider Enrollment and Management System (PEMS). TMHP is the single source for medical provider credentialing services and enrollment, re-enrollment, revalidation, change of ownership, and maintenance requests. While TMHP handles the enrollment process for Texas Medicaid, it’s important to understand that credentialing for participation in Medicaid Managed Care Organizations (MCOs) and Dental Maintenance Organizations (DMOs) has specific considerations.
Below is a breakdown of the requirements and processes.
1. Texas Medicaid Enrollment through TMHP:
- Online Enrollment via PEMS (Provider Enrollment and Management System): TMHP requires online enrollment through PEMS for medical provider credentialing services. This system provides a step-by-step guide for the application process. https://www.tmhp.com/topics/provider-enrollment/pems/start-application
- Required Information and Documentation: During the PEMS enrollment, you will need to provide various details and documents, which may include:
- National Provider Identifier (NPI): A valid 10-digit NPI is mandatory.
- Texas License or Certification: A current and unrestricted license or certification to practice in Texas.
- Provider Type Identification Form: Selecting the appropriate form based on whether you are enrolling as an individual, group, performing provider, or facility.
- Provider Information Form (PIF-1): For providers applying for Texas Health Steps enrollment more than one year after their initial Medicaid enrollment.
- Principal Information Form (PIF-2): For each principal, medical director, subcontractor, and creditor of the provider (if applicable).
- W-9 Form: Request for Taxpayer Identification Number and Certification.
- Electronic Funds Transfer (EFT) Agreement: If you wish to receive payments electronically, along with a voided check or bank letter.
- Copy of Facility License (if applicable).
- Texas Medicaid Provider Agreement: A signed agreement with the Texas Health and Human Services Commission (HHSC).
- Franchise Tax Account Status Page or IRS 501(c)(3) Exemption Letter (for incorporated providers).
- Corporate Board of Directors Resolution Form (for incorporated providers).
- Certificate of Formation/Authority/Incorporation (for incorporated providers).
- Disclosure of Ownership Form (for Texas Health Steps enrollment after one year).
- Proof of compliance with court-ordered child support (if applicable).
- Immigration documentation (if not a U.S. citizen).
- Complete Enrollment Before Providing Services: Providers must be fully enrolled in Texas Medicaid before they can be reimbursed for services. Providing services before enrollment is completed is done with the understanding that claims may not be payable if the application is denied.
- Enrollment Timeline: After TMHP receives all necessary information, the enrollment process can take up to 45 days, but it may be longer in certain circumstances.
- Texas Health Steps and CSHCN Services Program: Upon completing the Texas Medicaid provider application, qualified providers are automatically enrolled as Texas Health Steps medical checkup providers and Children with Special Health Care Needs (CSHCN) Services Program providers unless they choose to opt out during the application.
- Pharmacy and DME Enrollment: Pharmacies need to enroll in the Comprehensive Care Program (CCP) to provide drugs and supplies. A separate DME application is required for pharmacies wanting to be Durable Medical Equipment providers. Enrollment in the Vendor Drug Program (VDP) is a prerequisite.
2. Credentialing for Medicaid Managed Care Organizations (MCOs) and Dental Maintenance Organizations (DMOs):
- Separate Process: In addition to enrolling with Texas Medicaid through TMHP, providers who want to participate in STAR Medicaid, STAR Kids, STAR Health, Dual Medicare-Medicaid, and/or STAR+PLUS medical and dental plans must complete a separate credentialing application with each specific MCO or DMO.
- Prerequisite: Texas Medicaid Enrollment: You must be enrolled in Texas Medicaid before you can be contracted and credentialed by an MCO or DMO.
- Credentialing Verification Organization (CVO): All Medicaid MCOs in Texas are required to utilize the Texas Association of Health Plans’ (TAHP) contracted Credentialing Verification Organization (CVO) as part of their provider credentialing and recredentialing process.
- CVO Responsibilities: The CVO is responsible for receiving completed applications, attestations, and primary source verification documents.
- MCO Review and Approval: At least once every three years, the MCO must review and approve the credentials of all participating licensed and unlicensed providers in their network.
- Standard Credentialing Timeline: MCOs must complete the credentialing process for new providers and ensure their claims systems can recognize the provider as in-network no later than 90 days after receiving a complete application.
- Expedited Credentialing: Texas law requires MCOs to have an expedited credentialing process allowing providers to offer services on a provisional basis under certain circumstances (e.g., dentists, dental specialists, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, psychologists, and nursing facilities with a change in ownership). If a provider qualifies for expedited credentialing and submits a complete application, the MCO must treat them as in-network upon submission, including paying in-network rates for services rendered on or after the submission date, even if the full credentialing process isn’t yet complete. Their claims system must be able to process claims from these providers within 30 days of a complete application.
- PEMS Enhancement for Credentialing (Coming Soon – May 30, 2025): Starting May 30, 2025, PEMS will be updated to allow providers to complete and submit their credentialing information as part of the enrollment, re-enrollment, or maintenance process. While optional for initial Medicaid enrollment, those wanting to contract with MCOs/DMOs can complete the credentialing application concurrently. The CVO will still be responsible for verifying the information.
Key Takeaways:
To participate in Texas Medicaid managed care networks, providers must first enroll with Texas Medicaid through TMHP’s PEMS system. Following successful enrollment, they must then undergo a separate credentialing process with each MCO or DMO they wish to contract with. This credentialing process is facilitated by a CVO contracted through the Texas Association of Health Plans. The TMHP PEMS system will soon offer a way to initiate this credentialing information submission alongside the Medicaid enrollment process.
Always refer to the official TMHP website (https://www.tmhp.com/) and the websites of the specific Medicaid MCOs and DMOs you are interested in joining for the most current and detailed requirements and procedures.
Summary Table: Medicaid (TMHP & PEMS) Credentialing Steps in Texas
Step | Requirement/Action |
Medicaid Enrollment | Apply via PEMS; submit required documentation; complete screening and verification https://www.tmhp.com/topics/provider-enrollment/pems/start-application |
Managed Care Credentialing | Submit separate credentialing application for each MCO via PEMS (if participating) |
Documentation | Proof of education, licensure, board certification, work history, insurance, etc. |
Revalidation | Every 3–5 years, per federal and state guidelines |
Credentialing Verification | CVO conducts primary source verification for MCO insurance credentialing |
