August 10, 2022
Background
The Provider Enrollment and Management System (PEMS) fully deployed on December 13, 2021. The system introduced new business rules for enrollment in Texas Medicaid. Prior to the PEMS implementation, the provider billing effective date could be the Medicare enrollment effective date, the provider license date, or the application completion date (retroactive billing date).
With PEMS implementation, new and reenrolled provider agreement effective dates were upon signature of the agreements and required all screenings to be completed. After further review, HHSC, in collaboration with the Office of Inspector General (OIG) made the decision to allow retrospective billing effective dates in certain circumstances. The table below outlines those certain circumstances.
This policy applies to new enrollments and reenrollments only.
Key Details
The retroactive effective date appeared on the master provider file starting July 5, 2022. HHSC has directed Texas Medicaid & Healthcare Partnership to reprocess denied claims for providers. HHSC directs MCOs to allow for the reprocessing of claims for providers with the retroactive billing effective dates.
Questions
Providers, for questions or additional information, please:
- Contact your BCBSTX Medicaid Network team at 1-855-212-1615 or
- Submit via email Texas Medicaid Network Department
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.
| Applies to | Retroactive Billing Allowed? | Allowance | Criteria |
| Medicare Enrolled Providers with same Risk Category as Medicaid | Yes | The later of either the:
|
The following information must match between Medicaid and Medicare:
|
| Medicare Enrolled Providers with Higher Risk Category in Medicaid | No | Billing allowed only after the OIG completes all federally required screenings and recommends enrollment approval. | Elevated Medicaid Risk Categories Occur When:
|
| Medicaid-Only Providers | Based on Risk level | Moderate and High risk: Billing allowed only after the OIG completes all federally required screenings and recommends enrollment approval. Limited risk: Billing allowed back to provider application date |
Provider isn’t enrolled in Medicare; nothing to leverage. Limiting risk to state based on provider risk level. |