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 Provider Enrollment - PCCM

What is Primary Care Case Management (PCCM)?

PCCM is a network of Medicaid primary care providers (PCPs) and hospitals. It is not a health maintenance organization (HMO).

PCCM improves the provision of primary and preventive care services to Medicaid clients while ensuring the efficient use of limited Medicaid resources. 

The Texas Medicaid & Healthcare Partnership (TMHP) enrolls hospitals and PCPs. PCPs include doctors, nurses, clinics, and health centers.

PCPs are paid traditional fee-for-service rates plus an additional $3.90 per client, per month for each client who has selected them as their PCP.

A PCP can be a:

  • Physician (general practice, family practice, internal medicine).
  • Pediatrician.
  • Obstetrician/Gynecologist (OB/GYN).
  • Federally qualified health center (FQHC).
  • Rural health clinic (RHC).
  • Advanced practice registered nurse (e.g., nurse practitioner, certified nurse midwife).
  • Specialist who would like to serve as a PCP for patients with special needs (e.g., oncologist, pulmonologist).

What will be my responsibilities?

PCCM enlists PCPs to provide a medical home, where clients receive the majority of their primary care and obtain referrals to specialty care. Although clients are required to receive services and referrals through their PCP, referrals may be made to any Medicaid enrolled provider.

PCPs are responsible for hospital admissions and obtaining prior authorization for elective inpatient and outpatient procedures. Providers enrolling as PCPs must maintain admitting privileges at a PCCM-contracted hospital or facility or maintain a referral relationship with a Texas Medicaid-approved provider who has admitting privileges.

If the PCP does not have admitting privileges at a PCCM-contracted facility and the PCCM client needs treatment at the facility, the PCP must rely on another Texas Medicaid provider with admitting privileges to admit the client to the facility.

This can be done through a referral from the PCP to the Texas Medicaid-approved provider with admitting privileges. PCPs should have a referral arrangement in place with providers who have admitting privileges to facilitate ease in treatment of the client and administrative duties of the providers involved.

What do I have to do to become a Primary Care Provider?

PCCM PCPs are required to be credentialed by the Texas Health and Human Services Commission (HHSC) by completing a Texas Standardized Credentialing Application. When TMHP receives enrollment materials from the provider, the credentialing department reviews the documents to ensure completion and accuracy.

Once the enrollment forms are complete and accurate, the forms are forwarded to TMHP’s Medical Director for review. The findings from this review and verification process are presented to the Medical Director of HHSC for final credentialing determination at the Credentialing Committee’s monthly meeting. The decision to accept a provider as a PCCM PCP is made by HHSC in accordance with basic credentialing standards. PCCM notifies each approved provider in writing.

What forms will I need?

You will complete a Texas Standardized Credentialing Application along with the following. FQHCs or RHCs must complete the Medical Update form.

Can I submit these forms electronically?

Yes. To complete forms electronically, follow these steps:

  1. Create an account on this website.
  2. Click on the "I would like to" graphic in the banner.
  3. Click on Activate My Account and follow the steps to activate your account.
  4. Return to the "I would like to" web page, and click Access Provider Enrollment.
  5. Select Credentialing to begin the enrollment process.

Contact your TMHP Recruitment Representative for questions on how to enroll in Texas State Health-Care Programs.

 
   

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