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Presumptive Eligibility

Qualified Hospital/Qualified Entity Presumptive Eligibility

Notice of Intent

**Instructions - In order to complete the Notice of Intent (NOI) form, you must read and agree to the following regulations:

Contractor (QHQE Resource/Third-Party Entity) Roles:
Qualified hospitals and qualified entities may use contractors to assist them with the presumptive eligibility process. However, it is the qualified hospital or entity's responsibility to ensure their staff and contractors are assigned appropriate roles. Only qualified hospital or entity staff can make and submit presumptive eligibility determinations. Please refer to the Memorandum of Understanding (MOU) Section III. Hospital Responsibilities, “The Hospital will not delegate the authority to make PE determinations to another entity.” (Examples of a Qualified Hospital & Qualified Entity MOUs can be found on the Become a QH/QE tab). If contractors are found making or submitting presumptive eligibility determinations on behalf of the qualified hospital or entity, this will be grounds for dismissal from the program.

Only internal qualified hospital or entity staff may be listed on the Notice of Intent as the Contact Person and MOU Contact Person. Contractors may perform the administrative duty of submitting the NOI form only.

Only internal qualified hospital or entity staff are permitted to make and submit presumptive eligibility determinations. If this process is performed by contractor staff, the qualified hospital or entity may be immediately dismissed from the Presumptive Eligibility Program.

Contractors are limited to performing the following duties in the Presumptive Eligibility Program:

  • Access to the Presumptive Eligibility Portal to perform the following duties:
    • Benefit inquiry
    • Search for presumptive eligibility determinations
    • Link the presumptive eligibility determinations submitted by the qualified hospital or entity in YourTexasBenefits.com to the application for ongoing (regular) Medicaid.
  • Assist staff at welcome desks and meet individuals as long as the qualified hospital or entity takes responsibility for the presumptive eligibility determination
  • Access YourTexasBenefits.com to help individuals complete and submit regular (ongoing) Medicaid applications.


By clicking “Accept” you agree to the terms and conditions of these regulations.
Minutes before you can proceed by clicking "Accept"
If you have questions about being a Qualified Hospital or Qualified Entity or the presumptive eligibility process, visit Policy or contact HHSC at OSS_QHQE_PE@hhsc.state.tx.us.
Please provide the following information to inform the Texas Health and Human Services Commission (HHSC) of your election to make presumptive eligibility determinations as a Qualified Hospital or Qualified Entity. You must be approved by HHSC as a Qualified Hospital or Qualified Entity to make presumptive eligibility determinations.
Contractors (QHQE Resource/Third-Party Entity) have very limited roles in the PE process and cannot be designated as Staff, System Administrator, or Site Administrator for a QH/QE. Contractors may access the PE Portal, perform benefit inquiries, search for PE determinations, assist applicants in submitting a full Medicaid application, and link applications that have been submitted by the QH/QE through YourTexasBenefits.com. If it is found that a contractor is submitting PE determinations on behalf of QH/QE, this could result in disciplinary action, up to and include disqualification of the QH/QE from the Presumptive Eligibility program. The role of Staff, System Administrator, or Site Administrator can only be assigned to an employee of the QH/QE.
**Note – Only internal qualified hospital or entity staff are permitted to make presumptive eligibility determinations. Contractors may assist the qualified hospital or entity in the presumptive eligibility process but are prohibited from making and submitting a determination in the Presumptive Eligibility Portal.
If this process is performed by contractor staff, the qualified hospital or entity may be immediately disqualified from the Presumptive Eligibility program.
Your organization is interested in becoming a:
Name of Hospital/Entity * Other name (used for provider services)
Are you a Medicaid provider? * Texas Provider Identifier Number *
Organization type if not Medicaid provider Employer ID Number (EIN) *
Organization is
Mailing Address for Site
(no P.O. Box) 		* County *
City * Zip Code *
The contact person listed below will be the hospital or entity's system administrator. The website will create an account for this person using the email address listed below. When the Notice of Intent is approved, the website will create the account and email a temporary password.
Contact First Name (?) * Contact Last Name (?) *
Contact Title *
Telephone Number * Fax Number
Email Address *
The contact person listed below will be the Site Administrator. The website will create this person an account using the email address listed below. When the Notice of Intent is approved, the website will create the account and email a temporary password.
Contact First Name (?) * Contact Last Name (?) *
Telephone Number * Fax Number
Email Address *
The contact person listed below will be the backup contact for hospital or entity's system administrator.
Contact First Name (?) * Contact Last Name (?) *
Contact Title *
Telephone Number * Fax Number
Email Address *
If there are multiple hospitals in the systems or clinics associated with your hospital that will also be performing presumptive eligibility determinations, please indicate these below.
Name of Clinic/Hospital * Other name (used for provider services)
Are you a Medicaid provider? * Texas Provider Identifier Number *
Organization type of not Medicaid provider * Employer ID Number (EIN) *
Organization is
Mailing Address for Site
(no P.O. Box) 		* County *
City * Zipcode *
The contact person listed below will be the Site Administrator. The website will create this person an account using the email address listed below. When the Notice of Intent is approved, the website will create the account and email a temporary password.
Contact First Name (?) * Contact Last Name (?) *
Telephone Number * Fax Number
Email Address *

Sites

Number of sites added: 0
Please provide the details for the person who will be signing the Memorandum of Understanding (MOU). A link to sign the MOU will be sent to the email address provided below.
**Note-A Contractor may submit this document to apply for Presumptive Eligibility; however, the person signing the Memorandum of Understanding(MOU) and System Administrator(Contact Person) must be internal QH/QE staff. Contractors are prohibited from filling either of these roles
First Name * Last Name *
Title * Telephone Number *
Email Address *
I hereby certify that all the above information is true and accurate to the best of my knowledge.
By entering your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
*
Signature 		*
Title 		*
Date
Please complete, sign and click
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