The Puerto Rico Medicaid PEP is an online tool that allows providers, or their delegates, to submit an enrollment application for the Puerto Rico Medicaid Program (PRMP).
Federal regulations 42 CFR 431.107 (b) and 455.410 (b) require that the State Medicaid Agency, the PRMP under the Puerto Rico Department of Health, to enroll providers participating in the Medicaid program, including all the providers that order, prescribe, refer, provide and bill services to the Government Health Plan (Vital and Platino Plans).
Federal regulations 42 CFR 431.107 (b) and 455.410 (b) require the State Medicaid Agency (PRMP) to enroll providers participating in Government Health Plan (Vital and Platino Plans). PRMP is implementing the direct enrollment of providers to meet these regulations. Once a provider is enrolled, the MCO/MAO may contract with the provider to be part of their network.
The acronym MCO stands for Managed Care Organization. MCOs are healthcare provider organizations that provide medical services in a managed care arrangement. The Puerto Rico Medicaid Program (PRMP) contracts with MCOs to provide care for its Medicaid members.
Your unsubmitted application will expire after 30 days of no activity. If it expires, you must start over. The PEP will generate notices to remind you to complete and submit your application.
Enrollment will be conducted in waves, by provider enrollment types. Please see the wave schedule table for details.
Providers who fail to enroll by the deadline will not be eligible to participate in the PRMP in any role, including billing, rendering, operating and OPR providers.
Please refer to the checklist for your provider type for information and necessary documentation.
OOS providers must submit an application through PEP and must include an OOS attestation form. Please refer to the checklist.
Yes, you will need to enroll as an "individual" for your sole proprietor location and as an "individual within a group" for services you provide through the group.
All providers who render, bill for, order, prescribe or refer services for Medicaid beneficiaries under the Government Health Plan (Vital or Medicare Platino) must enroll directly with the PRMP through the PEP. In summary, all providers who are required to be indicated on a claim/encounter must enroll to be eligible for federal funding. Please refer to the "Who Must Enroll" guidance document for more information.
PRMP will provide training through the following methods: reference guides, navigation guides, computer-based training (CBT), the Learning Management System (LMS), web-based training sessions, and in-person training sessions. To take self-paced courses and register for training sessions please go to the LMS portal which will be available early March 2020.
Only certain provider types are permitted to enroll multiple locations under a single application. They are:
The individual physician needs to enroll with an enrollment type of ‘individual within a group’ and will need to associate this enrollment to the PMG. If the individual physician also performs services independently outside of the PMG, and additional application will need to be submitted with an enrollment type of ‘individual’. For the ‘individual’ enrollment, the PMG should not be associated.
The PEP collects provider associations. Associations define the business relationship between a group provider and its rendering provider members or associates. A medical group is a collection of doctors who have partnered with one another, contractually, to share the care of patients. A group association within PEP defines this relationship so that the group can bill for the services rendered by the group members. PEP also collects associations between ordering, referring, and prescribing providers who have privileges at facilities. In addition, PEP collects information about ownership which is separate from the associations defined above.
The associations that PEP collects should not be confused with affiliations that the MCOs collect. Affiliations define the relationships among providers and MCOs or MAOs and their benefit plans. Affiliations are based on contractual network relationships and not the business relationship between various providers. For instance, an IPA or PMG allows physicians who aren’t one combined corporate entity to enjoy the benefits of a larger organization in serving the needs of a health plan. The affiliations are defined by the health plan and represent the relationship each provider to the health plan and its type of relationship (PMG, preferred network, general network, not contracted) and the relationships between the providers (PCP to PMG, preferred network to PMG) as applicable.
To create an association in PEP a group must first have an approved enrollment in PRMP. Once the application for the PMG is approved, the PMG should inform its members of the PMG’s NPI and Medicaid ID. When the individual members enroll with an enrollment type of ‘individual within a group’, they will be responsible for associating to the PMG using the NPI and Medicaid ID.
A physician who is associated to multiple groups needs one application as enrollment type ‘individual within a group’. This application should be associated to every group in which the provider is a member. Physicians who also practice outside of the group(s) must also enroll as an enrollment type of ‘individual’.
The group should share their NPI and Medicaid ID with their associated individuals. Facilities should share their NPI Medicaid ID with their Ordering, Prescribing, and Referring (OPR) providers.
No. The associations in PEP define the business relation between group provider and its rendering member or associates. This enables the group to bill for the services rendered by the individuals within the group. The contractual relationships maintained by the MCOs define the affiliations that are based on the network within the MCO such as preferred network or general network.
Once your application via PEP has been approved, you can register for PSC. To complete your registration, you will need your Application Tracking Number (ATN), NPI or Tax ID.
As part of Federal Reg 42 CFR, Part 455.460, the application fee applies to "institutional" providers who are not already enrolled in Medicare or another state’s Medicaid program, or who have not paid an application fee to a Medicare contractor or to another state’s Medicaid program. The application fee does not apply to practitioners enrolling only as OPR providers. These providers are considered individual practitioners and are not subject to the fee, based on their provider type. Please refer to the application fee policy listed in the medicaid.pr.gov webpage in the section pertaining to the list of provider types that are subject to an application fee.
The application fee, as set by the Centers for Medicare and Medicaid Services (CMS), is $595.00 for calendar year 2020.
A bank manager’s check (cashier’s check) or money order is required to pay the fee. Please refer to the Provider Application Fee Instructions available here.
According to 42 CFR 455.101 Subcontractor means:
(a) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or
(b) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.
Examples include but are not limited to: Hospitals may subcontract with an ambulatory surgical center to perform some of its outpatient services. Hospitals may subcontract with a group of emergency physicians. A physician’s office may subcontract with an X-ray or laboratory provider. A subcontract for rental property is also considered to be included in the definition in the federal regulations 42 CFR 455.101.
Subcontractors for cleaning or cafeteria services are not included in the federal definition.
A surety bond is defined as a three-party agreement that legally binds together a principal who needs the bond, an oblige who requires the bond and a surety company that sells the bond. The bond guarantees the principal will act in accordance with certain laws. If the principal fails to perform in this manner, the bond will cover resulting damages or losses. The Puerto Rico Medicaid Program (PRMP) requires Home Health Agencies to obtain a surety bond that is the greater of $50,000 or 15 percent of the annual Medicaid payments made to the HHA by the Medicaid agency. The bond must list the Puerto Rico Medicaid Agency as the oblige.
If you have questions regarding your enrollment in the Puerto Rico Medicaid Program (PRMP), please submit your inquiry by email to: