Presumptive Eligibility

Notice of Intent

The Notice of Intent is a fillable form available on the Presumptive Eligibility website. The Presumptive Eligibility website also includes the Notice of Intent Instructions which explain the required information that must be submitted with the form.

The Notice of Intent must be signed electronically by an individual in a decision making capacity for the hospital/entity, and includes the following information:

• Hospital/entity name: The name of the hospital/entity with whom the MOU will be signed and will be held responsible for meeting program standards.
• Texas Provider Identifier (TPI) number: This number is mandatory for all Medicaid providers and will be used to verify status as a Medicaid provider through Texas Medicaid and Healthcare Partnership (TMHP).
• Contact person (System Administrator) and the person’s telephone number, email address, and mailing address.
• Hospital/Clinic name: Any clinic owned by a hospital that will be participating in the presumptive eligibility process must be provided.
• Clinic TPI number.
• Contact person (Site Administrator) and the person’s telephone number, email address, and mailing address.

Hospital/entity staff may participate at multiple locations within the same QH/QE system, but must identify all of the locations where they are participating. If an individual participates at multiple locations, that person will receive login information for each location so presumptive eligibility determinations can be accurately tracked to the locations. Each staff person’s role must be designated. The roles include:

• System Administrator: Individual who oversees the presumptive eligibility process for the hospital/entity system. This may be the same person as the Site Administrator.
• Site Administrator: Individual who oversees the presumptive eligibility process at the hospital/entity location.
• Staff: Individuals employed directly by the hospital/entity who will be making presumptive eligibility determinations.
• Contractor: Individuals employed by a third party that contracts with the hospital/entity. These individuals can help make presumptive eligibility determinations but may not make final determinations. A third-party entity or contractor is assigned the role of QHQE Resource in the PE process. They can assist the QH/QE in the PE process, but cannot make final PE determinations.