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Texas - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Texas Health and Human Services (HHSC) oversees the Case Management for Children and Pregnant Women (CPW) program, requiring applicants to secure an official HHSC approval letter before initiating Medicaid enrollment. Providers deliver comprehensive visits, family needs assessments, and follow-up monitoring for eligible Medicaid members across the state.

Applicants must complete a mandatory pre-planning process and HHSC standardized Case Management Training to receive the prerequisite approval letter. Once approved by HHSC, providers submit their enrollment application through the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment and Management System (PEMS) as either an individual or group provider.

1. Service Definition and Scope

Case Management for Children and Pregnant Women (CPW) provides assessment, person-centered service planning, referral, and monitoring for eligible Medicaid members. The service ensures individuals receive medically necessary, Medicaid-covered services and coordinates care across multiple systems.

Providers conduct comprehensive visits and follow-up visits to assess family needs and connect clients with appropriate resources. Effective July 1, 2024, prior authorization is no longer required for fee-for-service CPW program services.

2. Regulatory and Oversight Agencies

The Texas Health and Human Services Commission (HHSC) is the primary regulatory authority for CPW services, managing program rules, provider approvals, and policy development. HHSC issues the mandatory approval letter required for Medicaid enrollment.

The Texas Medicaid & Healthcare Partnership (TMHP) acts as the state's Medicaid claims administrator and manages the Provider Enrollment and Management System (PEMS) where approved providers complete their Medicaid enrollment.

3. Gatekeeping Prerequisites: Who Can Even Apply

Texas requires a specific pre-approval gate before a provider can enroll in Medicaid to bill for CPW services. Applicants cannot simply submit an application to TMHP; they must first obtain an HHSC approval letter.

To secure this letter, prospective providers must complete a pre-planning process and the HHSC standardized Case Management Training. This structural precondition blocks any applicant from entering the TMHP PEMS system without prior HHSC authorization.

4. Licensure and Certification Requirements

Texas does not issue a distinct facility license for CPW case management agencies. Instead, approval is based on the professional licensure or certification of the individual practitioners delivering the service.

Performing providers must hold a current and active license or certification from their respective Texas licensing or certification agency. Federally Qualified Health Centers (FQHCs) may also provide CPW services but must obtain HHSC approval and ensure their case managers meet specific professional requirements.

5. Medicaid Provider Enrollment

Once the HHSC approval letter is obtained, providers enroll in Texas Medicaid through the TMHP Provider Enrollment and Management System (PEMS). Providers must enroll exactly as HHSC approved them, either as an Individual Provider or a Group Enrollment.

During enrollment, providers must submit their HHSC approval letter and select the correct taxonomy codes based on their professional qualifications. The enrollment process through TMHP can take up to 60 business days for applications with no deficiencies.

6. Staffing, Training and Background Checks

Staff delivering CPW services must meet strict professional qualification standards and complete state-mandated training. The state requires that all case managers complete the HHSC standardized Case Management Training before the agency can be approved.

Providers must maintain active professional licenses or certifications and comply with standard Texas Medicaid background check requirements during the PEMS enrollment process.

7. Documentation, Policies and Records

Providers must ensure that all case management activities are documented and maintained in a client record. Documentation must comply with the Case Management for Children and Pregnant Women Rule, Medicaid Policy, and HIPAA.

HHSC provides specific mandatory forms for documenting the billable components of case management, including referrals, intake, and family needs assessments. These forms must be completed accurately to support claims.

8. Billing, Rates and Claims

CPW services are billed through TMHP for fee-for-service clients or through the respective Managed Care Organization (MCO) for managed care clients. Providers must verify client eligibility and MCO enrollment prior to delivering services.

Administrative procedures, including claims filing and encounter data submission, may differ between traditional Medicaid and specific MCOs. Providers must contact the member's specific MCO for detailed billing instructions.

9. Approval Sequence and Timeline

The approval sequence begins with contacting HHSC to initiate the pre-planning process and complete required training. Only after receiving the HHSC approval letter can a provider begin the Medicaid enrollment phase.

The TMHP enrollment phase involves submitting an application through PEMS, which undergoes screening and verification. Providers should anticipate a multi-month process from initial HHSC contact to final TMHP approval.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied if providers attempt to enroll in TMHP PEMS without first securing the HHSC approval letter. Deficiencies in the PEMS application, such as incorrect taxonomy codes or missing professional license data, will also halt the process.

During audits or reviews, common findings include failure to complete the comprehensive visit within the required 30 business days or missing mandatory HHSC forms (like CM-01A or CM-02) in the client record.

11. Key Contacts and Resources

Providers should utilize official HHSC and TMHP resources for the most current rules, forms, and enrollment guidance. The primary contact for initiating the CPW provider process is the HHSC CPW program email.

For technical assistance with the Medicaid enrollment application, providers must contact the TMHP Contact Center.

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