26 Tex. Admin. Code § 354.9 - Providers

(a) Applicable provider types for the program include, but are not limited to:

(1) pharmacies;

(2) hospitals; or

(3) blood banks.

(b) In order for a provider to qualify for participation and to enroll in the program, the provider will:

(1) be licensed by the state and practicing within the scope of their respective licenses, certifications, or registrations;

(2) be a current Texas Medicaid Program provider;

(3) enter into an agreement to participate in the program;

(4) submit a completed program provider enrollment form to the program;

(5) submit a completed department Child Support Certification form to the program;

(6) agree to reimburse the program for any overpayments made to the provider by the program upon request;

(7) not currently be on suspension as a program provider or as a Texas Medicaid Program provider; and

(8) not have a current exclusion documented with the following agencies;

(A) U.S. Department of Health and Human Services (HHS); or

(B) the Commission.

(9) Providers who have a suspension or exclusion documented will not be allowed to enroll with the program until the suspension or exclusion is resolved and removed.

(c) Changes in provider ownership require termination of the current agreement and a new agreement must be executed under the new ownership.

(d) The program may establish provider enrollment limitations in order to conserve funds, assure quality, and effectively administer the program.

(e) The program may modify, suspend, deny, or terminate a provider's approval to participate for the following reasons:

(1) submission of false or fraudulent claims;

(2) failure to provide and maintain quality services;

(3) failure to adhere to medically acceptable standards;

(4) breach of the provider agreement;

(5) disenrollment as a Texas Medicaid Program provider;

(6) placement on the current exclusion listing; or

(7) failure to submit a claim for reimbursement for an extended period of time, as specified by program policy.

Notes

26 Tex. Admin. Code § 354.9

Adopted to be effective December 14, 2008, 33 TexReg 10036; Amended by Texas Register, Volume 40, Number 15, April 10, 2015, TexReg 2091, eff. 4/16/2015; Entire chapter transferred from T. 25, Pt. 1, Ch. 37, Subch. F by Texas Register, Volume 47, Number 08, February 25, 2022, TexReg 0981, eff. 3/15/2022