Update to Provider Information Maintenance

Important information for providers: Texas Children’s Health Plan (TCHP) would like to inform providers that effective January 6, 2025, there will be changes in how TCHP will receive updates for provider directory information and provider network maintenance. This change will improve the provider experience by utilizing Texas Medicaid & Healthcare Partnership’s (TMHP) Provider Enrollment Management System (PEMS) data as the source of truth for populating demographics in the TCHP directory. 

This update will reduce administrative burden by capturing demographic updates automatically from the PEMS master file in lieu of providers sending in a Provider Information Change Form to TCHP directly.

Reminder about PEMS

PEMS is the required TMHP program which is the single tool for provider enrollment, reenrollment, revalidation, change of ownership, and maintenance requests (maintaining and updating provider enrollment record information) for Texas Medicaid. PEMS has automated and streamlined the process for provider ease of access by removing the requirement to use paper forms. 

Next steps for providers

Providers must ensure enrollment information in PEMS for groups, facilities, and individual providers is up-to-date and accurate for the TCHP directory to reflect the most current enrollment information. 

As a Managed Care Organization (MCO), TCHP will contract, credential and pay only those providers who are properly enrolled with TMHP and whose information is received in the official PEMS file from TMHP. In addition, it is important that every provider be enrolled at each location where they see patients. This is to help ensure claims process correctly.

How PEMS is accessed

PEMS is accessed through My Account. PEMS access is connected to the National Provider Identifier (NPI) or Atypical Provider Identifier (API) associated with the TMHP user account. Providers should ensure that the NPI has all the current and correct information. After a TMHP user account is created, follow these best practices for account management:

• Assign at least two administrators.
• Update user permissions as staff changes occur.
• Look for reminders for upcoming enrollment tasks on the Message Dashboard.

Provider directory elements automated through PEMS

TCHP will use PEMS as the source of truth for the below elements to populate in our provider directory: 

As a reminder for providers, as of November 22, 2024, Texas Medicaid providers must disclose whether their practice location is physically accessible to people with disabilities and whether their practice has a website. This applies to all provider types and practice locations.

Provider groups will also need to ensure that the individual providers billed on claims are enrolled and actively attested to the service location billed on claims.

The following data elements require providers to notify TCHP through the contracting and credentialing processes for inclusion in the provider directory: 

This is not an exhaustive list of the data elements that may be needed for the contracting and credentialing processes. 

Adding and terminating providers

• To add or terminate non-delegate providers, please reference the Cobblestone Gateway user guide. 
  • In PEMS, on the Provider Management page, providers have the option to remove a provider from their program practice record. Please send TCHP the term roster stating that the provider has been removed via Cobblestone Gateway.
• If providers are under a delegated agreement and would like to add or terminate delegate providers, please include the provider’s name and demographic information to submit the monthly rosters to TCHPdelegatedcred@texaschildrens.org. 

Demographic information changes

Changes to a provider’s demographic information will be imported from PEMS directly into TCHP’s systems.

Payment Denial Codes (PDC) in PEMS

TMHP’s weekly PEMS file will include providers with Payment Denial Codes (PDC) which will require termination from TCHP’s network. The PDC resulting in termination include the following: 

• Provider requested disenrollment
• Individual deceased
• Provider excluded, terminated or contract cancelled by the Office of Inspector General (OIG)
• Inactive number such as TIN not matched to correct provider identifier base 
• Provider identifier
• Medicare eligibility terminated
• Provider is not enrolled 
• Out of business
• Invalid NPI

Resources:

• Providers can learn more about Cobblestone Gateway by viewing the user guide
• For more information about PEMS, visit http://www.tmhp.com/topics/provider-enrollment and step-by-step guide on using PEMS, visit https://www.tmhp.com/topics/provider-enrollment/pems/start-application
• For PEMS educational videos, visit the TMHP YouTube channel
• Provider Alerts on PEMS: 
  • Updates and Actions Required for Implementation of PEMS Master Provider File Regarding Address Differences
  • Clarifying Information on Provider Enrollment and Management System (PEMS)

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

For access to all provider alerts,log into: www.texaschildrenshealthplan.org/provideralerts