Effective Date: 
12/2016

Documents

 

Instructions

Updated: 2/2017

 

Purpose

Form 3684 is completed by entities to apply for enrollment in Texas Medicaid and by existing providers to re-enroll in Texas Medicaid. A new applicant is required to enroll in Texas Medicaid as part of obtaining a Medicaid provider agreement to provide nursing facility services or intermediate care facility for individuals with intellectual disabilities (ICF/IID) services.

APPLICANT'S INSTRUCTIONS FOR COMPLETING FORM 3684

Note: Applicants that bill or intend to bill acute care services through Texas Medicaid & Healthcare Partnership (TMHP) must enroll in Texas Medicaid through TMHP. For more information, visit the Texas Health and Human Services (HHS) website at https://hhs.texas.gov/. Click on Doing Business With HHS at top of web page and then click on Medicaid Provider Enrollment under Texas Medicaid.

Carefully read the following instructions. Errors and omissions will cause delays in processing.

Section 1. Type of Enrollment — Check the New Enrollment box if you are a new applicant.

Check the Re-enrollment box if you are an existing HHS provider that is submitting an enrollment application before the end of your current enrollment period.

Section 2. Legal Entity Information

Name of Legal Entity — Enter the full legal name of the entity, exactly as it was chartered, filed, registered or otherwise legally declared. If the applicant is an individual, enter the full legal name of the individual.

Doing Business As (d/b/a) — If applicable, enter the d/b/a(s) relevant to this legal entity.

Federal Tax ID Number — Enter the employer identification number (EIN) assigned to the legal entity by the Internal Revenue Service (IRS). If the legal entity is a sole proprietorship or individual who does not have an EIN, enter the owner's or individual's Social Security number (SSN).

National Provider Identifier (NPI) — Enter the NPI number issued to the legal entity by the National Plan and Provider Enumeration System (NPPES).

Name of Owner — If the legal entity is a sole proprietorship, enter the owner's legal name. If the legal entity is not a sole proprietorship, leave blank.

Legal Entity Physical Address — Self-explanatory.

Fax Number — Enter area code and fax number.

Legal Entity Business Mailing Address — Self-explanatory. Enter “same” if same as physical address.

Contact Person — Enter the name of the person who can answer questions about the information furnished on the form.

Contact Telephone No. — Enter area code and telephone number.

Contact Email Address — Self-explanatory.

Contact Address — Self-explanatory.

Contact Title/Position with Legal Entity — Enter the contact person's title or relationship to the applicant's legal entity. Examples of title or relationship include CEO, partner, manager, executive director, authorized representative, etc.

Section 3. Type of Legal Entity — Check the applicable box.

Section 4. Type of Provider Check the applicable box.

Section 5. Provider Ownership Information — Self-explanatory.

Section 6. Adverse Actions and Convictions — Answer questions (a) through (f) Yes or No. If a question is answered Yes, provide the information requested.

For questions (a) and (b), "convicted" means that

  1. A judgment of conviction has been entered against an individual or entity by a federal, state or local court, regardless of whether:
    1. there is a post-trial motion or an appeal pending, or
    2. the judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed;
  2. A federal, state or local court has made a finding of guilt against an individual or entity; or
  3. A federal, state or local court has accepted a plea of guilty or nolo contendere by an individual or entity.

Convicted does not include successful completion of a period of deferred adjudication community supervision and receipt of a dismissal and discharge in accordance with Texas Code of Criminal Procedure, Article 42.12, Section 5(c).

For question (c), "sanction" is defined as recoupment, payment hold, imposition of penalties or damages, contract cancelation, exclusion, debarment, suspension, revocation or any other synonymous action.

Section 7. Internal Review Requirement — Answer the question Yes or No.

Note: A new applicant must screen its employees and contractors to determine if they have been excluded from Medicare, Medicaid or any federal or state health care program. The HHS Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) website is available at https://oig.hhs.gov/exclusions/ (link is external). The HHSC OIG LEIE website is available at https://oig.hhsc.state.tx.us/oigportal/EXCLUSIONS.aspx (link is external).

Section 8. Applicant/Re-enrolling Provider Certification

The owner or an authorized representative of the legal entity must certify the information provided on the form and all attachments, if any, is true and complete. If the legal entity is not a sole proprietorship, the authorized representative must be named on a current Form 2031, Governing Authority Resolution — Business Organization, or Form 2031-G, Governing Authority Resolution — Governmental Entity (whichever is applicable to the legal entity).

How to Submit Form 3684

In order to become a nursing facility or ICF/IDD provider, you must first apply for a license from HHSC. A new Texas Medicaid applicant must include Form 3684 in the HHSC license application packet. The mailing address for the HHSC license application packet is:

Texas Health and Human Services ARTS
Mail Code 1470
P.O. Box 149055
Austin, TX 78714

Important! The following documents must be included with Form 3684.

  • Attachment A, Application Payment Form
  • Application fee of $560.00: or
    • Proof of fee payment and enrollment in Medicare or another state’s Medicaid program or Children’s Health Insurance Program (CHIP); or
    • If requesting a waiver of the application fee due to financial hardship, a letter that details the reasons for the waiver and supporting documentation, which could include historical cost reports, financial records such as balance sheets and income statements, cash flow statements and tax returns. The letter must be signed and dated.

Retain copies of all documents submitted.

 

INSTRUCTIONS FOR HHSC STAFF

When to Prepare

Obtain a completed and signed Form 3684 for:

  • a new enrollment;
  • a change of ownership (if new owner is not currently enrolled in Texas Medicaid); and
  • a re-enrollment.

Form Retention

Retain Form 3684 and attachments in accordance with HHSC records retention requirements.

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