The following words and terms, when used in this chapter, have
the following meanings, unless the context clearly indicates otherwise:
(1) Applicant--An individual or an entity that submits
an enrollment application to enroll or re-enroll as a provider or
to enroll a new practice location in Medicaid or CHIP as described
in paragraph (7) of this section.
(2) CHIP--The Texas State Children's Health Insurance
Program established under Title XXI of the federal Social Security
Act (42 U.S.C. §§1397aa, et seq.) and Chapter 62 of the
Health and Safety Code.
(3) Change of ownership--A change of ownership related
to a partnership, sole proprietorship, corporation, or leasing arrangement
as defined in 42 CFR §489.18.
(4) Designee--An entity to which HHSC has delegated
certain functions for provider enrollment purposes. A designee may
(A) an HHSC contractor;
(B) a health and human services agency; or
(C) a managed care organization (MCO) that contracts
with HHSC under Medicaid or CHIP.
(5) Disenroll--To end a provider's participation in
Medicaid or CHIP before the end of the provider's current enrollment
(6) Enrollment--The process for applying to become
a provider, including contracting and procedures for determining whether
to grant approval to enter into a provider agreement.
(7) Enrollment application--Documentation required
by HHSC that an applicant submits to HHSC to enroll or re-enroll as
a provider or to add a new practice location. An enrollment application
includes supplemental forms used to add practice locations for Medicare-enrolled
or limited-risk providers, as determined by HHSC.
(8) Enrollment type--A type of enrollment category
that identifies how the applicant seeks to enroll, such as individual,
group, performing provider, or facility.
(9) Entity--A provider group, a facility, an organization,
or a business registered with the Texas Secretary of State.
(10) Health care practitioner--A physician or non-physician
licensed or certified health care provider who is recognized by federal
law or by HHSC as a provider who can bill for medical services or
benefits, submits orders or referrals for services to treat, certifies
medical need for services, or supervises other individuals providing
services and benefits to Medicaid or CHIP recipients.
(11) Health and human services agency--A state agency
identified in §531.001(4) of the Government Code.
(12) HHSC--The Texas Health and Human Services Commission
or its designee.
(13) Medicaid--The medical assistance program, a state
and federal cooperative program authorized under Title XIX of the
Social Security Act that pays for certain medical and health care
costs for people who qualify.
(14) National Provider Identifier--A unique ten-digit
identification number assigned by the Centers for Medicare & Medicaid
(15) Overpayment--A payment made to a provider in excess
of the amount that is allowable for the service provided, plus any
(16) Person with an ownership or control interest--Has
the meaning assigned by §371.1003 of this title (relating to
(17) Provider--An applicant that successfully completes
the enrollment process outlined in this chapter and in Chapter 371
of this title (relating to Medicaid and Other Health and Human Services
Fraud and Abuse Program Integrity).
(18) Provider agreement--An agreement between HHSC
and a provider wherein the provider agrees to certain contract provisions
as a condition of participation.
(19) Re-enrolling provider--A provider that submits
an enrollment application before the end of the provider's current
(20) Recipient--A person receiving benefits under Medicaid
(21) Surety bond--One or more bonds issued by one or
more surety companies under 31 U.S.C. §§9304 - 9308 and
31 CFR parts 223, 224, and 225.
(22) Terminate--To take an adverse action against a
provider whose participation in Medicaid or CHIP has ended at federal
or state agency direction due to violation of state rules or federal
(23) Third-party billing vendor--A vendor registered
with HHSC or its designee that submits claims for reimbursement on
behalf of a provider.