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REV. XII
Privacy Statement
With a few exceptions, Texas privacy laws and the Public Information Act entitle you to ask about the information collected on this form, to receive and review this information, and to request corrections of inaccurate information. The Health and Human Services Commissions (HHSC) procedures for requesting corrections are in Title 1 of the Texas Administrative Code, sections 351.17 through 351.23. For questions concerning this notice or to request information or corrections, please contact Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126.
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Introductions and Provider Agreement Dear Healthcare Professional: Thank you for your interest in becoming a Texas Medicaid Provider. Participation by providers in the Medicaid program is vital to the successful delivery of Medicaid services, and we welcome your application for enrollment. As a potential new provider to the Medicaid program, 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 your application will be approved for processing or that you will be assigned a Medicaid Texas Provider Identifier (TPI) number. If you make the decision to provide services to a Medicaid client prior to approval of the application, you do so with the understanding that, if the application is denied, claims will not be payable by Medicaid, and the law also prohibits you from billing the Medicaid client for services rendered.
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95 days of the date of service on the claim, or within 95 days from the date a new TPI is issued for in-state providers and providers located within 200 miles of the Texas state border 365 days from date of service for out-of-state providers
The Texas Medicaid Provider Procedures Manual contains important information about provider responsibilities, filing deadlines and procedures, and much more. It is also available for you to download at http://www.tmhp.com or you may call 1-800-925-9126 to request a printed copy. For information about Medicaid TPI requirements, the status of your enrollment, or claims submission, call TMHP Contact Center toll-free at 1-800-925-9126. TMHP customer service representatives are available from 7 a.m. to 7 p.m. central standard time. Thank you for your enrollment in the Texas Medicaid Program. Sincerely,
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Table of Contents
Texas Medicaid Identification Form...............................................................................................................2 Required Forms for Medicaid Enrollment......................................................................................................3 Useful Information..........................................................................................................................................4 Frequently Asked Questions .........................................................................................................................5 Texas Medicaid Provider Enrollment Application .............................................................................. 7.1 - 7.4 HHSC Medicaid Provider Agreement................................................................................................ 8.1 - 8.7 Provider Information Form (PIF-1)..................................................................................................... 9.1 - 9.3 Principal Information Form (PIF-2) .................................................................................................... 9.4 - 9.6 Disclosure of Ownership and Control Interest Statement Form.................................................... 10.1 - 10.2 IRS W-9 Form..............................................................................................................................................11 IRS W-9 Instructions...................................................................................................................... 12.1 - 12.3 Corporate Board of Directors Resolution Form ...........................................................................................13 Medicaid Audit Information Form.................................................................................................................14 Optional Enrollment Forms (Index) .........................................................................................................15 Electronic Claims Submission (ECS) and Electronic Remittance and Status (ER&S) Notification ............16 Electronic Funds Transfer (EFT) Information ..............................................................................................17 Electronic Funds Transfer (EFT) Authorization Agreement Form...............................................................18 Texas Vaccines for Children Program (TVFC) Provider Enrollment ............................................. 19.1 - 19.3 Appendix A Enrollment Requirement by Provider Type ......................................................... 20.1 - 20.9 Final Checklist ............................................................................................................................. 21.1 - 22.2
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Traditional Services