ATTENTION COMMUNITY FIRST PROVIDERS
Collaborative testing between Texas Health and Human Services Commission (HHSC) and Managed Care Organizations (MCOs) has identified Provider address differences between the MCOs ecosystem and the Master Provider File (MPF) extracted from Provider Enrollment and Management System (PEMS).
Because of these address differences, the effective date for PEMS Master Provider File has yet to be determined.
HOW THIS IMPACTS PROVIDERS
Providers with mismatched addresses will receive communication directly from Community First Health Plans. Communication will include the date Providers must complete the address update in PEMS and address update requirements.
Providers are strongly encouraged to follow the PEMS guidance provided in forthcoming communications. Meeting the address synchronization between MCOs and PEMS will proportionately reduce claim denials for Providers and improve the accuracy of encounter reporting and network adequacy to MCOs.
Important: Providers that neglect to update their address information within the specified period provided by Community First will experience the following:
- Payment denial code will be applied by PEMS if the Provider is not actively enrolled in PEMS
- Community First will reject the claim for those Providers not actively enrolled in PEMS
ADDITIONAL INFORMATION
- Address differences were found for several Provider types affiliated with different programs and facilities, including but not limited to the nursing facility.
- The address differences may lead to operational problems for MCOs, including but not limited to paying the Provider claims whose Providers are not actively enrolled in the PEMS.
- The address differences were caused by the rules incorporated with the implementation of PEMS, which included requirements to align performing Provider addresses to the address of the group they are associated with in the TMHP legacy systems.
RESOURCES
- “How to update the Provider address in PEMS” YouTube video
- TMHP Contact Center: 800-925-9126 (Select option 3 for questions about updating Provider address)
- Community First Provider Relations: 210-358-6294 | ProviderRelations@cfhp.com