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Deadline Approaching: Avoid Medicaid Provider Disenrollment

As a requirement of the Patient Protection and Affordable Care Act (PPACA), state Medicaid agencies must revalidate the enrollment of all providers in state Medicaid programs. The original re-validation deadline was March 24, 2016, and was extended by the Centers for Medicare and Medicaid Services (CMS) to allow states additional time to process provider applications. For Texas Medicaid, this means all providers, including ordering and referring providers, who have not met all PPACA revalidation requirements must do so through re-enrollment by Sept. 24, 2016 (see resources at the bottom of this article for information on how to verify your re-enrollment status). 

To avoid disenrollment on Sept. 25, 2016, and possible disruption in claims payment, providers should submit a re-enrollment application to the state or TMHP today.

Applications Received On or Before June 17, 2016

To avoid potential disruption in payment, a complete re-enrollment application must be received on or before June 17, 2016 in order to be re-validated by Sept. 24, 2016. For Texas Medicaid, this means all providers, including ordering and referring providers, who have not met all PPACA revalidation requirements must do so through re-enrollment by Sept. 24, 2016.  Complete applications that are received on or before June 17, 2016, will most likely complete the re-enrollment process by Sept. 24, 2016. In the event that the re-enrollment process is not completed by Sept. 24, 2016, and the provider is still working toward addressing identified deficiencies at that time, the provider will continue to remain enrolled in Texas Medicaid as long as the provider continues to respond to deficiency notifications within the defined timeframe for response. Continued enrollment is contingent upon continuing to meet deficiency correction timelines and receiving final application approval. Providers should submit a re-enrollment application to the state or TMHP today.

Applications Received After June 17, 2016

Texas Medicaid will normally process complete applications received on or after June 17, 2016; however, Texas Medicaid cannot guarantee that those applications will be completely processed by the Sept. 24, 2016 deadline.  If final approval on an application received after June 17, 2016 is not completed by Sept. 24, 2016, the provider will be dis-enrolled from Texas Medicaid. Providers including, but not limited to, ordering and referring providers, will be dis-enrolled from Texas Medicaid with an effective date of Sept. 25, 2016 if the application is received after June 17, 2016, and a final determination on the application is pending. Though these applications will continue to be processed, a gap in enrollment will exist between Sept. 25, 2016, and the date the application is approved. Providers whose applications are denied will remain dis-enrolled with an effective date of Sept. 25, 2016. Providers with a gap in Medicaid enrollment will not be eligible to receive reimbursement for claims with dates of service during the time the provider is not enrolled in Texas Medicaid. If the re-enrollment application is approved at a later date, the re-enrollment date will be the date the application was approved. The effective date will not be retroactive to the date the provider was dis-enrolled. Additionally, dis-enrolled providers will not be eligible to participate in Medicaid managed care organizations (MCOs) or dental maintenance organizations (DMOs) during the dis-enrolled period.

Programs Required to Re-enroll

This re-enrollment requirement applies to providers who participate in Medicaid managed care, traditional fee-for-service Medicaid (each active TPI Suffix), the Texas Vendor Drug Program (VDP), and in long term care services administered through the Texas Department of Aging and Disability Services (DADS).

Information for Acute Care and Pharmacy/DME providers re-enrolling through TMHP:

Information for Long Term Care (LTC) only providers with a DADS Medicaid contract re-enrolling through DADS:

Information for Vendor Drug Program (VDP) providers re-enrolling through VDP:
VDP providers should receive a targeted outreach communication from the Vendor Drug Program with specific information for this provider type.

Information for Medicaid MCO Long-Term Services and Support (LTSS) providers:
There is a separate enrollment process for these LTSS providers who bill MCOs and do not have an active DADS Medicaid contract and do not have a TPI for the same provider type to bill TMHP for acute care services. These providers are required to re-enroll through the Medicaid MCO LTSS provider re-enrollment process. LTSS providers who are unaware of their DADS contract status may contact DADS at: Texas.Medicaid.Enrollment@dads.state.tx.us to verify contract status and establish next steps.

Information for Ordering and Referring-Only providers:
Ordering- and referring-only providers are those providers whose only relationship with Texas Medicaid is ordering or referring services for Medicaid clients. These providers are now required to enroll with Texas Medicaid as participating providers.