Medicaid and CHIP Provider Enrollment and Revalidation: Enrollment Gap Flexibilities, Closures, & Claims Reprocessing

Date: February 25, 2025

Attention: All Providers

Revalidation update: Health and Human Services Commission (HHSC) is implementing provider enrollment revalidation flexibilities due to the significant challenges Medicaid providers are experiencing in complying with enrollment revalidation timelines and requiring all Medicaid and CHIP MCOs like Texas Children’s Health Plan (TCHP) to support these flexibilities. HHSC will extend revalidation due dates, and reduce or eliminate enrollment gaps, and require payers like TCHP to support claims reprocessing efforts.

How this impacts providers: Texas Medicaid & Healthcare Partnership (TMHP) and HHSC are implementing a process to modify enrollment period effective dates for providers that:

Were dis-enrolled for failing to revalidate timely between November 1, 2023, and December 12, 2024.
Successfully re-enrolled in Texas Medicaid

The implementation of this process will be in two phases.

Phase 1 has 2 options:

Option 1: This option began on January 17, 2025, providers that meet both the criteria above, Phase 1 will result in their National Provider Identifier (NPI) enrollment period begin date in the Provider Enrollment and Management System (PEMS) to potentially be backdated up to 365 calendar days. Providers will receive an email notification with their new NPI enrollment period begin date.

Option 2: For any providers with draft or in-flight revalidation or reenrollment requests that are approved after January 17, 2025, the following will apply. Their NPI enrollment period start date in PEMS will be backdated up to a maximum of 365 calendar days to reduce or eliminate their enrollment gap.

Phase 2 Overview

Beginning February 22, 2025, the change to the enrollment period end date will also be reflected as a new revalidation due date to align with state and federal revalidation frequency requirements. Providers will receive an email notification with their new NPI enrollment period end date.

Claims Reprocessing

Beginning February 2025, to be eligible for claims reprocessing, providers must meet the following criteria:

Have been dis-enrolled for failing to revalidate timely between November 1, 2023, and December 12, 2024
Successfully reenrolled in Texas Medicaid by January 17, 2024
Did not re-enroll in Texas Medicaid by January 17, 2024

Claims Reprocessing of Previously Denied Claims

Claims reprocessing will begin in February 2025, with all adjustments completed by June 30, 2025. One of the following will happen with claims based on a provider’s enrollment status.

a. Claims, which have zero gaps on the Master Provider File/PEMS, will be adjusted for payment- no interest paid.

b. Claims, which do not meet the provider enrollment requirements will remain denied and will not be adjusted.

Consistent with the guidance from TMHP, providers with claims that do not meet provider enrollment requirements, are allowed 95 days from the notice date to submit claims. Timely filing will be waived during the 95-day period only.

Next step for Providers: Providers must follow the guidance provided in this communication. TCHP posts ongoing communication online about the provider enrollment revalidation process so it is recommended that you visit our provider alert webpage regularly for the latest information. That webpage is available at https://www.texaschildrenshealthplan.org/for-providers/provider-news.

Resources:

Providers with questions should attend one of the upcoming webinars on the revalidation process and enrollment periods. For more information, visit https://www.texaschildrenshealthplan.org/providers/provider-events
For more information about PEMS overall, visit http://www.tmhp.com/topics/provider-enrollment
Step-by-step guide on using PEMS, visit https://www.tmhp.com/topics/provider-enrollment/pems/start-application

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org

For access to all provider alerts: https://www.texaschildrenshealthplan.org/providers/provider-news/provider-alerts