Provider Enrollment Portal (PEP)

Puerto Rico Medicaid Management Information System (PRMMIS)

Why Is This Important?

• Ensures that providers are qualified
• Ensures that Puerto Rico Medicaid Program (PRMP) is in compliance with federal regulations
• Reduces the risk of fraud
• Ensures that members receive quality care

Federal & State Regulations

• Mandated by CMS, federal regulations 42 CFR § 431.107 and 455.410
• Required by PR Medicaid Program: PRDoH Administrative Order #404

Provider screening includes, but not limited to:

• Facility Licensure (SARAFS)
• Individual Licensure (ORCPS)
• Controlled Substance Certificate
• Local Police Screening (Penal Record)
• Fingerprint Social Security Death Master File
• Background Check (PRBCP)
• EPLS/SAM (Excluded)
• LEIE (OIG)
• PECOS (Medicare)
• NPPES (NPI Data)
• DEA (Narcotics)
• CLIA (Laboratories)

All providers connected to the covered service must enroll:

• Billing
• Rendering
• Ordering
• Referring
• Prescribing
• Operating
• Attending

Communication Plan

February 2020 through Go-live:

• Share timelines, scope, policies and instructions to navigate the LMS, PEP and PSC modules.
• Schedule and complete trainings through LMS system.

Process Flow

1. Collect provider enrollment information and supporting documentation via PEP.
2. Validate provider enrollment information and screen providers.
3. Approve providers application for participation.
4. MCOs/MAOs receives data on providers.
5. MCOs/MAOs contracts with providers.
6. MCOs/MAOs notifies PRMMIS of providers and PMG/PCP Affiliations