Texas Medicaid Provider Enrollment and Credentialing: TMHP PEMS, STAR and CHIP Plans, the Texas Standardized Credentialing Application, and Novitas Medicare

Texas splits a new provider's paperwork across at least four systems. The clock column repeats only what the manual, statute or plan publishes; none of it is a forecast for a particular file, and each clock assumes a complete application.

Every Texas Medicaid enrollment, from a solo physician to a hospital system, goes through PEMS, and the provider manual is blunt about sequence: "All providers must be enrolled in Texas Medicaid before enrollment can be approved for any other service or program, including, but not limited to, Medicaid managed care." HHSC's enrollment page adds that the requirement reaches ordering- and referring-only providers too.

1. Pick the right request type. TMHP's PEMS step-by-step guide lists New Enrollment (an NPI never enrolled in Texas), Existing Enrollment (add a location or program), Revalidation, Reenrollment (after disenrollment, termination or exclusion), Maintenance, and two transportation-only types. A New Enrollment filed for an NPI that already has a record is a wasted request.
2. Enroll under the correct NPI type. PEMS builds each record on the NPI. Individual, performing and sole-proprietor providers use an Individual NPI; groups and facilities of any size use an Organization NPI.
3. Have Medicare in hand, or the waiver language ready. See the next section; for most physicians this decides whether the application can be submitted at all.
4. Check the license dates. The manual says providers "cannot enroll in Texas Medicaid if their license or certification is due to expire within 30 days of application."
5. Complete owner and disclosure screens. The Owner/Creditor/Principal entries and the Disclosure of Ownership and Control Interest Statement are required, and they are where Medicare mismatches surface.
6. Upload entity documents if you are a corporation. Texas asks for the Franchise Tax Account Status page from the Comptroller (or the IRS 501(c)(3) letter) and the Certificate of Formation or Certificate of Filing, and the name on that certificate "must exactly match the legal name shown on the W-9 form."
7. Pay the application fee if your provider type owes it, then e-sign the HHSC Medicaid Provider Agreement, which certifies that everything submitted is complete and correct.

Two PEMS housekeeping rules catch people. A draft that is never submitted expires after 180 calendar days, and TMHP emails the person who created it 30 days before that happens; an expired draft cannot be revived. And TMHP's How to Apply page notes that a review may involve a site visit or an HHSC approval before the notification letter arrives, which lists your next revalidation date.

Texas is stricter than many states here. The provider manual, citing 1 TAC 352.13, says Medicaid providers "that perform Medicare-covered services must be enrolled in or certified by Medicare, unless HHSC waives the requirement or grants an exception," and an application without that waiver "must include a valid, current Medicare number." For a group, each performing provider needs a Medicare number unless an exception is on file.

HHSC may waive the requirement for providers who deliver only services Medicare does not cover, or who see only patients who are not Medicare-eligible; the manual gives pediatrics and OB/GYN as examples. The waiver is an attestation inside PEMS, and its wording commits you to enroll in Medicare if that changes and to report the Medicare number within 10 days of enrolling. If Medicare later covers a service you provide, the manual gives 90 days to enroll.

TMHP reinforced the point on October 16, 2026: for dual-enrolled providers, each owner, creditor or principal's name, date of birth, Social Security number, legal entity name and EIN must be consistent between Medicare and Texas Medicaid, and "discrepancies between Medicare and Texas Medicaid records may result in a deficiency delaying the enrollment process." TMHP also says Medicare updates must be approved before the matching change is submitted in PEMS, and to allow up to 30 business days after a Maintenance request before starting a revalidation. In practice that means the Novitas file gets fixed first.

The TMHP provider enrollment phone number is 800-925-9126, Option 3, the TMHP Contact Center line that both HHSC and TMHP's Enrollment Help page publish for PEMS questions; the email address is provider.relations@tmhp.com. Children with Special Health Care Needs Services Program enrollment has its own line, 800-568-2413.

Status lives in PEMS itself. Each request appears on the Requests page, and TMHP treats a request as finished only at Closed–Enrolled. Newly enrolled providers get a notification email the day after approval, and the effective date is printed on the Welcome Letter in PEMS. Anyone can confirm another provider's enrollment, including ordering and referring physicians, in TMHP's Online Provider Lookup.

Texas does not have a statutory enrollment deadline like some states. Its published standard is in the Texas Medicaid Provider Procedures Manual: "After receipt of all information necessary to process the application, the entire application process can typically take up to 60 days." The same paragraph says requests for exceptions, risk-category reviews and provider types needing extra state approval extend it.

The manual states two different cure windows, and both matter:

• Incomplete applications: "Providers will be notified of incomplete applications and will have 30 business days to provide the requested missing information," after which TMHP ends the process and a new application is required.
• Online deficiencies: among the advantages of PEMS, the manual lists "165 cumulative business days will be provided to correct all deficiencies," and providers can edit a submitted application to fix them.

Read together, a single missing-information request is on a 30-business-day fuse, and a file that keeps bouncing back has a lifetime budget. Treat every deficiency notice as urgent.

When you can bill. Claims may be filed for dates of service on or after the effective date. A newly enrolled provider's claims must reach TMHP within 95 days of the date enrollment is complete and within 365 days of the date of service, so services provided during enrollment are not lost if they are filed promptly once the Welcome Letter arrives. A denied application can be challenged by an informal desk review requested through PEMS within 20 business days when the denial followed an OIG recommendation, or 30 calendar days for any other denial.

Texas screens at initial enrollment, revalidation and reenrollment based on each provider type's categorical risk level, under 42 CFR 455.410 and 455.450, and a reenrolling provider is screened at the same level as a brand-new one. Two Texas-specific consequences: providers in the moderate or high category "cannot render or submit claims for services at a new practice location until it has been approved and added to the enrollment record," and high-risk enrollments add fingerprinting (TMHP keeps a Provider Fingerprinting Requirement FAQ on its How to Apply page).

The application fee follows the federal rule: institutional providers pay it on new enrollments, new practice locations, revalidations and reenrollments, through the Application Fee page in PEMS, unless they already paid it to Medicare or another state's Medicaid program or CHIP, in which case they submit proof instead. TMHP keeps the list of provider types that owe it on its website. Individual practitioners such as physicians are not institutional providers. We did not find the current dollar amount on a Texas page, so we do not quote one here.

"Most providers have an enrollment period of five years," TMHP says, although some carry one- or two-year periods. Revalidation opens in PEMS 180 days before the due date, HHSC's page asks providers to submit "at least 120 days before the end of their enrollment period," and a request submitted before the due date that reaches Closed–Enrolled within the 45-day grace period counts as on time with no gap.

The penalty for missing it is wide: the provider is disenrolled "from all Texas state health care programs, including Medicaid managed care organizations (MCOs) and dental maintenance organizations (DMOs)," claims and prior authorizations deny, and the only path back is a reenrollment application with new-provider screening.

Two recent changes. Senate Bill 1266 (2025) added Government Code 532.01512: before disenrolling a provider for an unfinished revalidation, HHSC must send written notice electronically and by mail at least 30 days ahead and let the provider fix the deficiencies first. And HHSC's page reports that CMS asked states on April 23, 2026 for a two-year off-cycle revalidation strategy, which Texas submitted on June 5, 2026, so a notice can arrive before your printed due date. TMHP also changed its due-date extension rules for due dates from June 16, 2026; check the PEMS dashboard rather than relying on an older extension.

A physician who never bills Texas Medicaid but orders labs, imaging, DME or therapy for a Medicaid patient still has to enroll. The manual requires individual providers whose only relationship with Texas Medicaid is ordering or referring to "enroll in Texas Medicaid as participating providers," and the requirement extends to orders for dually eligible patients and to CHIP. Providers who are out of network for a patient's MCO do not need a separate ordering/referring enrollment. Residents holding only a Physician-in-Training permit from the Texas Medical Board cannot enroll; their supervising physician is reported as the ordering provider. This is a common reason a therapy or DME claim denies for a reason the billing office cannot see.

Most Texas Medicaid members are in managed care. HHSC describes the programs this way: STAR for pregnant women, low-income children and their caretakers; STAR+PLUS for adults with disabilities and people 65 and older; STAR Kids for children and youth 20 and younger with disabilities; STAR Health for children in foster and kinship care; and CHIP for children whose family income is above the Medicaid limit. HHSC says seventeen MCOs and three dental maintenance organizations serve these members.

The manual's rule is two-step: be enrolled in Texas Medicaid, "and then must enroll with the client's health plan." Credentialing for every Medicaid MCO runs through one statewide credentialing verification organization. The Texas Association of Health Plans' provider resource (last updated July 19, 2024) lays out the order:

1. Enroll with Texas Medicaid through TMHP.
2. Request a contract from each MCO you want to join.
3. After the contract is submitted, the MCO starts credentialing and Verisys, the statewide CVO, sends a letter asking you to complete the credentialing application. If you are contracting with several plans at once, say which plans may use the application so one submission serves them all.
4. The plan notifies you of acceptance. Recredentialing is every three years, aligned by Verisys across your Medicaid plans, with a reminder letter 90 days before the due date.

Blue Cross and Blue Shield of Texas's Medicaid credentialing instructions confirm that Verisys (formerly Aperture) is "the CVO that all Medicaid MCOs use for credentialing and recredentialing." The legal basis is Government Code 532.0151, which lets HHSC designate a centralized credentialing entity and require every Medicaid MCO to use it, and Government Code 540.0657, which lets the recredentialing cycle under that consolidated process be longer than three years. Since September 1, 2025, Section 532.01511 also requires HHSC to provide a support team for the enrollment and credentialing portal and an electronic complaint form.

Expedited credentialing for Medicaid. Government Code 540.0656, amended effective September 1, 2025 to name federally qualified health centers and their providers, requires each Medicaid MCO to let a qualifying applicant see members "on a provisional basis." To qualify, the provider must have a current MCO contract or belong to a contracted group or FQHC, already be Medicaid-enrolled, agree to the contract terms, and submit everything the MCO needs to start credentialing. The plan then pays as if the provider were in network; if credentialing later fails, it may recover the difference between in-network and out-of-network payments, or everything it paid if the application was fraudulent.

TAHP's 2024 contact table lists credentialing contacts for Aetna Better Health, Blue Cross and Blue Shield of Texas, Community First Health Plans, Community Health Choice, Cook Children's Health Plan, Dell Children's Health Plan, Driscoll Health Plan, El Paso Health, Molina, Parkland, BSW Health Plan, Superior HealthPlan, Texas Children's Health Plan, UnitedHealthcare Community Plan and Amerigroup. Plans change by service area, so confirm the current list for your county before requesting contracts. STAR+PLUS long-term services and supports providers contract and credential with the member's MCO in the same way.

The Texas Standardized Credentialing Application is TDI form LHL234 (Rev. 01/07), the application every Texas hospital, HMO and PPO plan must use to verify a physician's credentials. Insurance Code 1452.052 directs the commissioner to prescribe one form for physicians, advanced practice nurses and physician assistants and requires public and private hospitals, HMOs and preferred provider plan issuers to use it. TDI's credentialing form page (updated April 30, 2025) says use "by hospitals, HMOs and PPOs is required for credentialing of physicians" and that they may use it for other professionals too.

What to know before filling it in:

• Where it goes: to the plan or workers' compensation network you want to join, not to TDI. Ask the plan about its process first.
• The package: TDI's forms listing has the main application (LHL234) and seven attachments for overflow entries: other professional degrees (A), post-graduate education (B), work history (C), current and previous hospital affiliations (D and E), practice locations (F) and malpractice claims history (G).
• The PDF trap: TDI warns that entries typed into the interactive PDF are lost if you close it in the free Acrobat Reader; print before closing, or save with Acrobat Professional.
• Questions: TDI lists MCQA@tdi.texas.gov.

How it relates to CAQH. TDI says the Texas form "is based on one developed by the Coalition for Affordable Quality Healthcare," and in practice most plans now read CAQH ProView instead of a paper TSCA. BCBSTX's Medicaid instructions are a clear example: provider types on CAQH's approved list must apply through CAQH, and professionals whose type is not on that list complete the Texas Standardized Credentialing Application and fax or mail it with their state license, DEA certificate, malpractice face sheet, a summary of malpractice cases from the last 10 years, and the signed attestation page. Keep both current: the CAQH profile needs re-attestation every 120 days (CAQH quick reference), and our CAQH explained page walks through it.

Texas gives three provider groups a payment bridge with commercial managed care plans. Subchapters C, D and E of Insurance Code chapter 1452 cover physicians licensed by the Texas Medical Board, podiatrists licensed by TDLR, and therapeutic optometrists licensed by the Texas Optometry Board, each only when joining an established group or practice that already has a contract with the plan. Once the applicant submits everything the plan needs to begin credentialing and agrees to the group's contract terms, the plan must treat them as participating "for payment purposes only," including collecting copays.

The plan may keep the applicant out of its directory until approval. If credentialing ultimately fails, the plan can recover the difference between in-network and out-of-network payments from the provider or group, the patient is held harmless, and the practice keeps copays already collected. The same chapter limits HMOs: the commissioner cannot require formal recredentialing more often than once in any three-year period or a site visit for recredentialing (Section 1452.004).

Texas Medicare Part A and Part B enrollment is processed by Novitas Solutions, the Jurisdiction H contractor for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma and Texas, plus Indian Health Service and VA providers. The CMS fee-for-service enrollment contact list gives its provider enrollment line as 855-252-8782, Option 4, with paper correspondence to JH Provider Enrollment Services, P.O. Box 3095, Mechanicsburg, PA 17055-1813. Home health and hospice enrollment for Texas goes to Palmetto GBA instead.

Physicians and groups apply in PECOS on the CMS-855I or CMS-855B. Novitas publishes no Texas-specific turnaround, so the governing standard is the one CMS sets for every MAC in Program Integrity Manual chapter 10: an online application with no site visit, development request or fingerprinting is processed 95% of the time within 15 calendar days and always within 50; with any of those, 50 and 85 days. Paper filings run 30 and 65 days, or 65 and 100. Under 42 CFR 424.521, a physician may bill Medicare for services up to 30 days before the effective date when circumstances prevented earlier enrollment. Because Texas Medicaid wants a valid Medicare number for most physicians, the Novitas approval is usually the first domino. Our Medicare provider enrollment guide covers the forms and PECOS steps.

Railroad Retirement Board beneficiaries in Texas have their Part B claims paid by Palmetto GBA, not Novitas, so the practice also needs a Railroad Medicare PTAN. Palmetto's enrollment instructions (published January 13, 2026) say the Novitas Part B enrollment must exist first; Palmetto then creates its record from that enrollment when you request a PTAN through its PTAN Lookup and Request Tool, without a new CMS-855, dates the Railroad PTAN to your Part B effective date, and asks you to allow up to 30 days. Electronic claim enrollment with Palmetto is a separate step. Request it as soon as the Novitas letter arrives rather than when the first railroad retiree's claim rejects.

The files we see stall in Texas usually stall on data the practice supplied, not on TMHP or the plans. Texas's own documents point at the same culprits:

• Medicare and Medicaid owner records that disagree. TMHP's October 2026 notice names name, date of birth, SSN, legal entity name and EIN for each owner, creditor or principal. A mismatch is a deficiency.
• A W-9 name that differs from the Secretary of State certificate. Texas requires an exact match for corporations.
• No Medicare number and no waiver. A physician who performs Medicare-covered services cannot finish PEMS without one or the other.
• A license inside its last 30 days. Texas will not enroll on it.
• Deficiency notices that sit. Thirty business days for missing information is not long when the notice goes to a former office manager.
• Drafts left in PEMS. They expire at 180 days.
• Assuming TMHP enrollment equals network status. STAR and CHIP plans pay only after their own contract and Verisys credentialing.
• A stale CAQH attestation or old addresses on NPPES, the license or CAQH, which stall every commercial plan reading them.
• A missed revalidation, which ends participation in every Texas program at once.

Our process is built for exactly that: one file checked field by field against PECOS, PEMS, NPPES, the board and CAQH before anything is submitted, then a weekly follow-up with every payer, logged with the representative's name, the date and the reference number.

Expect to need the individual and group NPIs with current NPPES addresses, the W-9 and IRS letter, the Texas license and its expiration date, DEA and state controlled-substance details where applicable, the Medicare PTAN (or the waiver basis), malpractice coverage, owner and managing-employee details with dates of birth and SSNs entered identically to PECOS, the Comptroller franchise tax status page and Secretary of State certificate for corporations, bank information for EFT, practice locations, and a current CAQH profile. The complete list and the secure way to send it are on what we need from you to start credentialing.

If the difference between enrollment, credentialing and contracting is still fuzzy, our page on what provider credentialing is separates them. The federal Medicaid rules every state shares, and links to each state's process, are on Medicaid provider enrollment. For other states, see provider credentialing in Florida and provider credentialing in Kentucky, and for national plans the payer-by-payer credentialing hub.

ClaimCarePro takes a Texas practice through Novitas Medicare, TMHP PEMS, the STAR and CHIP plans and Verisys, the Texas Standardized Credentialing Application or CAQH for commercial payers, and the Railroad Medicare PTAN, with every payer followed up weekly and logged. Flat pricing: $250 per payer application per provider, CAQH setup $250, re-credentialing $250, maintenance $99 per provider per year, or the new-practice bundle at $1,750 per provider ($1,400 each additional provider on the same group and payers). Start credentialing now and get a secure start link within one business hour, or call (844) 772-8902. More on the service is at provider credentialing services, and keeping enrollments current is covered on recredentialing.

Updated October 23, 2026. All sources were read on October 23, 2026 unless noted. If a manual, statute or plan document changes, the linked source governs over this article. Statutory summaries are not legal advice.

• Texas Medicaid Provider Procedures Manual, Vol. 1, Section 1, Provider Enrollment and Responsibilities, October 2026 edition (manual page last updated September 30, 2026): tmhp.com manual index; Section 1 PDF (60-day statement; managed care sequence; 1 TAC 352.13 Medicare requirement and waiver; 30-day license rule; 30 business days and 165 cumulative business days; entity documents; screening, fee, revalidation; ordering/referring; desk review; 95-day and 365-day filing)
• TMHP, Provider Enrollment: tmhp.com; How to Apply (last updated February 25, 2026): tmhp.com; PEMS step-by-step guide: tmhp.com; Enrollment Help: tmhp.com (800-925-9126, Option 3; provider.relations@tmhp.com)
• TMHP news, Preventing Medicaid Enrollment Delays: Ensure Your Medicare Information Is Current and Accurate (October 16, 2026): tmhp.com
• TMHP PEMS: secure.tmhp.com/pems; Online Provider Lookup: opl.tmhp.com
• Texas HHSC, Medicaid Provider Enrollment: hhs.texas.gov (five-year revalidation, 120 days, CMS April 23, 2026 request and Texas June 5, 2026 strategy, separate MCO contracting)
• Texas HHSC, Medicaid and CHIP Quality and Efficiency Improvement: hhs.texas.gov (program definitions; 17 MCOs and 3 DMOs)
• Texas Insurance Code chapter 1452, Physician and Provider Credentials: tcss.legis.texas.gov (1452.004; 1452.052; subchapters C, D, E)
• Texas Government Code chapter 540 (eff. April 1, 2025; 540.0656 amended by H.B. 3151, eff. September 1, 2025): tcss.legis.texas.gov; chapter 532 (532.0151; 532.01511 and 532.01512 added by S.B. 1266, eff. September 1, 2025): tcss.legis.texas.gov
• Texas Department of Insurance, Texas Standardized Credentialing Application (page updated April 30, 2025): tdi.texas.gov; credentialing forms listing: tdi.texas.gov
• Blue Cross and Blue Shield of Texas, Initial Credentialing and Recredentialing Process, Medicaid network (undated PDF): bcbstx.com
• Texas Association of Health Plans, Credentialing Provider Resource (last updated July 19, 2024): tahp.org
• CMS, Medicare Fee-for-Service Provider Enrollment Contact List (undated): pecos.cms.hhs.gov; Novitas Solutions: novitas-solutions.com
• CMS, Medicare Program Integrity Manual, chapter 10 (read October 23, 2026 for our Medicare enrollment page): cms.gov
• 42 CFR 424.521 (read October 23, 2026 for our Medicare enrollment page): ecfr.gov
• Palmetto GBA, Enroll in Railroad Medicare (published January 13, 2026; read October 23, 2026 for our Medicare enrollment page): palmettogba.com
• CAQH ProView Provider Quick Reference (read October 16, 2026 for our CAQH page): caqh.org

Not found, and therefore not stated: a statutory or contract day count for Texas Medicaid MCO credentialing, the current application-fee dollar amount on a Texas page, a complete current list of MCOs by service area, and the text of TMHP's June 16, 2026 revalidation-extension notice.