Reimbursement: State and Federal Programs 
Becoming a Provider in State and Federal Health Insurance Programs
Medicare
In 1965, the Social Security Act established both Medicare and Medicaid. Medicare is a federal health insurance program that provides coverage to approximately 40 million Americans including:
- People age 65 or older
- Some people under age 65 with disabilities
- People with End-Stage Renal Disease (ESRD)
The Center for Medicare and Medicaid Services (CMS) is the federal agency that administers the Medicare Program. CMS contracts with various regional intermediaries/carriers to process claims and handle provider relations. TrailBlazer is the carrier for Texas and several other states. Therefore, TrailBlazer will process your Medicare provider application and answer any questions.
You must apply for a National Provider Identifier (NPI) before applying to the Medicare Program. See the article on the NPI.
The Medicare enrollment form for APNs is Form CMS 855I. Additional information is available on the CMS Website.
These forms can not be submitted electronically. They must be printed; the certification statement must be signed and dated, and mailed to:
TrailBlazer Health Enterprises, LLC
Provider Enrollment TX
P.O. Box 650544
Dallas, TX 75265-0544
Toll free Provider Enrollment Helpline is (866) 528-1602.
Call Monday-Friday between 8:00 a.m. and 4:00 p.m. CT.
Also, for information on Medicare Part A and Part B, visit the TrailBlazer Home Page and the CMS Home Page.
There are a number of very good references on Medicare reimbursement through the Medicare Learning Network.
For information on "Incident to Services," see Carolyn Buppert’s article on Incident to Billing, and the MLN Matters article #SE0441.
Medicaid
Medicaid is jointly funded by Federal and State governments to assist states in providing medical and long-term care assistance to people who meet certain eligibility criteria. Within broad national guidelines established by Federal statutes and CMS regulations and policies, each State (1) establishes its own eligibility standards; (2) determines the type, amount, duration, and scope of services; (3) sets the rate of payment for services; and (4) administers its own program. Therefore, Medicaid policies for eligibility, services, and payment vary considerably from state to state.
The Texas Medicaid Program began in 1967 and the Health & Human Services Commission (HHSC) is the state agency responsible for administering the program. As the costs of the Medicaid program have increased, Medicaid serives are increasingly being provided through managed care. For more information on the Texas Medicaid Program and development of Medicaid managed care, refer to Texas Medicaid in Perspective.
HHSC contracts with the Texas Medicaid & Healthcare Partnership (TMHP), a coalition of contractors, to provide the Medicaid provider relations and claims payment functions. TMHP also administers the Primary Care Case Management managed care service delivery model.
Therefore, APNs become providers in the Texas Medicaid Program through TMHP. Most providers must be enrolled in Medicare before they can enroll as a Medicaid provider. Exceptions include PNPs, pediatricians, and those only enrolled to provide Texas Health Steps screening exams. In addition, TMHP may waive the Medicare enrollment prerequisite for other physicians or APNs whose type of practice and service may never be billed to Medicare, such as CNMs.
To enroll as a provider in the Texas Medicaid Program, download the Medicaid Provider Enrollment Application and Instructions and mail the application to:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin , TX 78720-0795
If you have questions about the application, call Provider Enrollment: 1-800-925-9126, Option 2
TMHP also enrolls providers' and administers' claims for several other programs for the State of Texas. To find more information about all of these state programs, click on the following links:
For more detailed information on Texas Medicaid, see the Health and Human Services Commission Web site.
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