|(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
(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
(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.