Texas State Compliance

STAR · STAR+PLUS · STAR Kids · CHIP

CHO ships with platform-level Texas Medicaid compliance rules that apply automatically to any tenant operating TX managed care lines of business. TMHP PEMS enrollment verification, HHSC UMCM prior authorization rules, Gold Card exemption tracking, and TX-specific fee schedules are built in — not bolted on. Tenants can layer overrides or disable rules through the Blazor portal admin UI, but platform rules cannot be deleted.

TMHP PEMS Provider Enrollment

The Texas Medicaid & Healthcare Partnership (TMHP) operates the Provider Enrollment & Management System (PEMS) — the authoritative source for Texas Medicaid provider enrollment status. CHO integrates directly with PEMS through the TmhpPemsSource adapter in the ProviderEnrollmentService.

What CHO Does

The TmhpPemsSource adapter queries PEMS for active enrollment status per NPI. When the enrollment gate is enabled or enforced for the tenant, inbound claims and prior authorization requests trigger an enrollment check before processing continues.

Data Returned

Claims Gate Integration

Claims from unenrolled or terminated providers are stopped before adjudication. The StateEnrollmentGate evaluates PEMS enrollment status and returns a pass/fail decision with a reason code. This prevents payment for services rendered by providers who are not actively enrolled in the Texas Medicaid program.

LOB Mapping

TMHP returns raw LOB codes that CHO normalizes into typed enums:

• TMHP LOB code → Star (Medicaid managed care — children and families)
• TMHP LOB code → STARPlus (adults with disabilities, age 65+)
• TMHP LOB code → StarKids (children with disabilities)
• TMHP LOB code → CHIP (Children’s Health Insurance Program)

Resilience

For Texas enrollment checks, the MultiStateEnrollmentAggregator routes the lookup to the TMHP PEMS source configured for TX; it does not fall through to CAQH ProView for cross-source failover. In production, resilience comes from TMHP-specific safeguards such as cached enrollment results and configurable warn-mode gating, allowing Cloud Health Office to continue processing during transient TMHP degradation without misrepresenting the source of truth.

Configuration

Two configuration keys are required, both stored in Azure Key Vault under the provider enrollment service section:

• ProviderEnrollmentService:Tmhp:BaseUrl — TMHP PEMS API endpoint
• ProviderEnrollmentService:Tmhp:ApiKey — API authentication key

Prior Authorization Rules — TX Programs

CHO ships with 14 platform-level seed rules covering three Texas Medicaid programs. These rules are sourced from the HHSC Uniform Managed Care Manual (UMCM) Chapters 4, 5, and 6, and are loaded by the PriorAuthRuleEngineSeeder on first deployment.

Gold Card Exemption (All TX Programs)

The TxGoldCardExemptionRule evaluates at Priority 1 — it runs before all clinical rules in the engine. If a provider qualifies for gold card status, the request is auto-approved without clinical review.

How it works: The rule evaluates provider history — total decisions must meet the minimum threshold AND the approval rate must be ≥90%. When both criteria are met, the provider is auto-approved. Gold card status applies across STAR, STAR+PLUS, and STAR Kids programs.

Rule IDs: TX-STAR-REG-001, TX-STARPLUS-REG-001, TX-STARKIDS-REG-001

STAR Program Rules

STAR covers children, pregnant women, and families. Source: HHSC UMCM Chapter 4.

STAR+PLUS Program Rules

STAR+PLUS covers adults with disabilities and individuals age 65+. Source: HHSC UMCM Chapter 5.

STAR Kids Program Rules

STAR Kids covers medically dependent children. Source: HHSC UMCM Chapter 6.

Rule Management

• 14 platform seed rules ship with every CHO deployment
• Loaded by PriorAuthRuleEngineSeeder on first deployment
• Admin UI: Tenants can override parameters, disable rules, or add tenant-level rules via the Blazor portal
• Platform rules are immutable — ensures the regulatory floor is never removed
• Rule category: RegulatoryExemption (Gold Card runs at Priority 1)

TX Medicaid Fee Schedules

CHO ingests HHSC/TMHP published rate tables for Texas Medicaid programs. Fee schedules are program-specific and resolved at claim time by the FeeScheduleEngine.

• Ingestion: FeeScheduleLoaderService imports rate tables with effective dating
• Resolution: FeeScheduleEngine resolves the correct rate at claim time per program/LOB and date of service
• Effective dating: Historical rates are preserved — claims are priced against the schedule effective on the date of service, not the current schedule

Compliance Pipeline Summary

All TX compliance components chain together at claim/authorization time. Here is the end-to-end flow for a Texas Medicaid prior authorization request:

1. Request arrives — 278 transaction or FHIR PAS $submit operation
2. ProviderVerificationEngine — NPI validation, OIG exclusion check, PECOS Medicare enrollment verification
3. ProviderEnrollmentService — TMHP PEMS enrollment check (active TX Medicaid enrollment required)
4. PriorAuthRuleEngine — TX seed rules execute in priority order:
   • Gold Card exemption (Priority 1 — auto-approve if qualified)
   • Visit/quantity limits (chiropractic, PT/OT)
   • Diagnosis requirements (power wheelchair)
   • EPSDT under-21 exemption
5. Decision or pend — Auto-approve, auto-deny, or pend for clinical review
6. SLA Watchdog — TX turnaround requirements: 72 hours for urgent requests, 14 calendar days for standard
7. Write determination — Result written to system of record (QNXT in augment mode, CHO in replace mode)

Adding Your State

CHO’s multi-state architecture is extensible. The same enrollment adapter, rule engine, and fee schedule pipeline pattern supports California (CA PAVE), Florida (FL FMMIS), and New York (eMedNY) today, with the same Source → Aggregator → Gate pattern.

Each new state requires:

• An IEnrollmentSource adapter for the state’s enrollment portal
• State-specific seed rules in SeedRules/ implementing UMCM-equivalent regulations
• Fee schedule rate tables from the state Medicaid agency

Contact us to discuss your state’s requirements.

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