Please follow the Enrollment Instructions below to become an electronic submitter for Texas Medicaid.

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed, and returned to the Medicaid office prior to initiation of electronic claim submission or inquiry.

• Trading Partner Application and Enrollment Form
• EDI Trading Partner Agreement
• EDI Agreement (for LTC Providers Only)

If you have any questions regarding any of the documents in this package, please call the TX Medicaid EDI Technology Support Center at 888-863-3638

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Trading Partner Application and Enrollment Form

Contact Information

• Please enter your contact name

• Please enter your address

• Please enter your email address and phone number

• Please enter your state

Entity Type

• Please select "Billing Agent, Business Agent, or Third-Party Billing Vendor"

Subcontractor

• Please check the box "Not Applicable"

Access Type

• Please select your type of business

Subcontractor Information

• Please check the box "Not Applicable"

Data Collection, Use, and Retention

• Please check the box "Yes" if your organization retains copies of the data you will be sharing with TMHP

• If you selected "Yes", please indicate how long you retain the data and for what purpose

Access to Information

• Please check the box "No"

EDI Trading Partner Agreement

Section 3

• Please enter your NPI and Provider Name

Section 4

• Please enter your Provider or Company Name

• Please enter your address

• Please enter your Contact Name

• Please enter your phone number

• Please enter your email address

Section 5

• Please sign your name next to "By:"

• Please print your name

• Please enter your title

• Please enter today's date

EDI Agreement for LTC Providers

• On page 5 please enter the date, the legal name of provider, and your TX Medicaid Provider Number

• On page 6 please enter the legal name of Provider, Sign, Print Name/title, then enter your address

• Please re-enter the same information on pages 7 and 8

• On page 9 please enter provider name, address, provider number and phone number

• On page 10 please check the box for "I will use some other software" then enter "Axiom Systems" for our name

• Please check the box for 837 Institutional if you bill UB 04 claims or 837 Professional if you bill on a CMS 1500

• Please sign, print your name, title and today's date

• On page 11 please enter your provider number, name, address, phone, fax, email address then sign and date

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the original trading partner agreement and EDI Enrollment forms reflecting original signatures to:

Texas Medicaid & Healthcare Partnership
Attn: EDI
PO Box 204270
Mail stop — EDI-B14
Austin, TX 78720-4270

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Please allow up to 30 days for processing.

After processing, a Submitter ID will be assigned for end-to-end system testing. If neither confirmation nor a returned packet is received after 30 days, please contact the TX Medicaid EDI Technology Support Center at 888-863-3638.

Once you've been assigned a Submitter ID, please send an email to: ediconnectivitysupport@tmhp.com providing your company name, tax ID, NPI, TX Provider ID, and newly assigned Submitter ID and let them know you wish to send via SFTP. They will provide the credentials for submitting via SFTP.

Testing

Once you have received your Submitter ID, SFTP Login ID and Password from TX Medicaid, please call the ClaimShuttle Support Team at 602-439-2525 and set an appointment for a Mailbox setup and Test Transmission to Medicaid.

Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.