SECTION 352.5. Provider Enrollment Requirements

(a) Enrollment in Medicaid or CHIP is required for:

(1) a person or an entity seeking to provide health care services or benefits in Medicaid or CHIP; and

(2) a health care practitioner who:

(A) refers, orders, prescribes, certifies, or renders health care services or benefits for eligible recipients; or

(B) supervises or is supervised by another health care practitioner who performs the functions described in subparagraph (A) of this paragraph.

(b) Prerequisites for enrollment.

(1) Prior to submitting an enrollment application, the applicant or re-enrolling provider must conduct an internal review to confirm that neither the applicant or the re-enrolling provider, nor any of its employees, owners, managing partners, or contractors (as applicable), have been excluded from participation in a program under Title XVIII, XIX, or XXI of the Social Security Act.

(2) The applicant must apply and receive a National Provider Identifier (NPI) in accordance with §1128J(e) of the Social Security Act (42 U.S.C. §1320a-7k(e)). If the applicant provides a service that is not recognized for an NPI, the state may, in its sole discretion, issue an atypical provider identifier to the applicant.

(3) An applicant or re-enrolling provider must meet the criteria in §352.13 of this chapter (relating to Medicare Certification or Enrollment in Medicare).

(4) An applicant or re-enrolling provider must not be terminated from participation in Medicare, another state's medical assistance program, or CHIP.

(5) An applicant or re-enrolling provider must be licensed, certified, or accredited to the extent required by federal and state laws, regulations, statutes, rules, and policy. The applicant or re-enrolling provider must be in good standing related to licensure, certification, and accreditation to be considered for enrollment.

(6) An applicant or re-enrolling provider that is considered out-of-state must meet the requirements for out-of-state provider eligibility in accordance with §352.17 of this chapter (relating to Out-of-State Medicaid Provider Eligibility).

(7) An applicant or re-enrolling provider must consent to criminal background checks, including fingerprinting when required to do so by state or federal law.

(8) As applicable, an applicant or re-enrolling provider must obtain a surety bond pursuant to §352.15 of this chapter (relating to Surety Bond Requirements) for each enrollment location.

(9) An applicant or re-enrolling provider must ensure that, if a third-party billing vendor is used for claim submission, the third-party billing vendor is registered with HHSC pursuant to §354.1187 of this title (relating to Responsibilities of Third-Party Billing Vendors).

(10) An applicant or re-enrolling provider must consent to unscheduled and unannounced pre- and post-enrollment site visits conducted by HHSC or its designee.

(11) An applicant or re-enrolling provider must certify that it has a compliance program containing the core elements as established by the Secretary of Health and Human Services referenced in §1866(j)(8) of the Social Security Act (42 U.S.C. §1395cc(j)(8)), as applicable.

(c) A provider must submit a new enrollment application and comply with §352.7(a) of this chapter (relating to Applying for Enrollment) at least every five years. The time frame for re-enrollment is based on the provider's screening level unless HHSC determines a shorter enrollment period.

Source Note: The provisions of this §352.5 adopted to be effective December 31, 2012, 37 TexReg 9899