Health and Human Services Commission (HHSC)
Provider Finance Department
Texas Hospital Disproportionate Share (DSH) and Uncompensated Care (UC)
Application Request Form
HHSC is currently accepting application requests for Federal Fiscal Year (FFY) 2023 Disproportionate Share Hospitals (DSH) and Demonstration Year (DY) 12 Uncompensated Care (UC) Program Payments.
Providers may find eligibility, qualification, the conditions to participate, and payment allocation methodology in the DSH program in 1 Texas Administrative Code (TAC) Part 15, Sec.
§355.8065
, and the criteria for calculating the Hospital Specific Limit (HSL) used in the DSH program in Sec.
§355.8066.
Providers may find eligibility and payment allocation methodology for the DY 12 UC program in 1 TAC Part 15, Sec.
§355.8212
for hospitals and
§355.8214
for physician groups. Effective in FFY 2020/DY 9, UC will reimburse for uncompensated uninsured charity care costs instead of Medicaid and uninsured costs.
An application fee will be required with the submission of the UC application for all non-public providers. The application fee will be determined annually based upon an estimate of the amount equal to the estimated costs necessary to administer the program. Please refer to Texas Administrative Code §
355.8200
for more information regarding the UC application fee.
HHSC will collect the data for FFY 2023 DSH and DY 12 UC in one DSH/UC Application. The data for the FFY 2023/DY 12 program year is FFY 2021.
Due Date for submission: September 30, 2022
Please complete the following form if the Hospital wishes to participate in the FFY 2023 DSH program and/or DY 12 UC.
The form must include the name and all contact information of the person requesting the DSH/UC Application, the person preparing the application, and up to three additional contracts the hospital wishes to receive DSH/UC correspondence from HHSC.
HHSC will send hospital applications to the contracts provided on or around the week of October 24, 2022. Providers will have 30 days to complete with the option to request a 15-day extension starting on November 18, 2022. The physician applications will not be sent until January 2023.
The Medicaid Appeals Period to submit an HSL/Medicaid claims appeals to TMHP starting on October 29, 2022 and has a deadline of November 30, 2022 by 5:00 PM.
For questions regarding the content of the form, please send an email to
the PFD Hospitals mailbox.
For technical questions regarding the website, please contact the
Provider Finance Department Help Desk
.
 
Hospital Medicare Number (CCN)
Hospital TPI Number
Hospital TPI Number
(related to data year, if different from current year)
Hospital NPI Number
Provider Ownership Type
Physician Group - State
Physician Group - Non-State
Private
Private IMD
Public
State/IMD
State Chest Hospital (TCID)
State Teaching
Must select one from list
Hospital Name
Hospital DBA Name (if any)
Hospital System Name (if applicable)
Hospital Physical Address
City
TX
Zip
 
County
Select
Anderson County
Andrews County
Angelina County
Aransas County
Archer County
Armstrong County
Atascosa County
Austin County
Bailey County
Bandera County
Bastrop County
Baylor County
Bee County
Bell County
Bexar County
Blanco County
Borden County
Bosque County
Bowie County
Brazoria County
Brazos County
Brewster County
Briscoe County
Brooks County
Brown County
Burleson County
Burnet County
Caldwell County
Calhoun County
Callahan County
Cameron County
Camp County
Carson County
Cass County
Castro County
Chambers County
Cherokee County
Childress County
Clay County
Cochran County
Coke County
Coleman County
Collin County
Collingsworth County
Colorado County
Comal County
Comanche County
Concho County
Cooke County
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Cottle County
Crane County
Crockett County
Crosby County
Culberson County
Dallam County
Dallas County
Dawson County
Deaf Smith County
Delta County
Denton County
DeWitt County
Dickens County
Dimmit County
Donley County
Duval County
Eastland County
Ector County
Edwards County
El Paso County
Ellis County
Erath County
Falls County
Fannin County
Fayette County
Fisher County
Floyd County
Foard County
Fort Bend County
Franklin County
Freestone County
Frio County
Gaines County
Galveston County
Garza County
Gillespie County
Glasscock
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Gray County
Grayson County
Gregg County
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Guadalupe County
Hale County
Hall County
Hamilton County
Hansford County
Hardeman County
Hardin County
Harris County
Harrison County
Hartley County
Haskell County
Hays County
Hemphill County
Henderson County
Hidalgo County
Hill County
Hockley County
Hood County
Hopkins County
Houston County
Howard County
Hudspeth County
Hunt County
Hutchinson County
Irion County
Jack County
Jackson County
Jasper County
Jeff Davis County
Jefferson County
Jim Hogg County
Jim Wells County
Johnson County
Jones County
Karnes County
Kaufman County
Kendall County
Kenedy County
Kent County
Kerr County
Kimble County
King County
Kinney County
Kleberg County
Knox County
La Salle County
Lamar County
Lamb County
Lampasas County
Lavaca County
Lee County
Leon County
Liberty County
Limestone County
Lipscomb County
Live Oak County
Llano County
Loving County
Lubbock County
Lynn County
Madison County
Marion County
Martin County
Mason County
Matagorda County
Maverick County
McCulloch County
McLennan County
McMullen County
Medina County
Menard County
Midland County
Milam County
Mills County
Mitchell County
Montague County
Montgomery County
Moore County
Morris County
Motley County
Nacogdoches County
Navarro County
Newton County
Nolan County
Nueces County
Ochiltree County
Oldham County
Orange County
Palo Pinto County
Panola County
Parker County
Parmer County
Pecos County
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Potter County
Presidio County
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Randall County
Reagan County
Real County
Red River County
Reeves County
Refugio County
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Rockwall County
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Rusk County
Sabine County
San Augustine County
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San Saba County
Schleicher County
Scurry County
Shackelford County
Shelby County
Sherman County
Smith County
Somervell County
Starr County
Stephens County
Sterling County
Stonewall County
Sutton County
Swisher County
Tarrant County
Taylor County
Terrell County
Terry County
Throckmorton County
Titus County
Tom Green County
Travis County
Trinity County
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Victoria County
Walker County
Waller County
Ward County
Washington County
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Wichita County
Wilbarger County
Willacy County
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Zavala County
Hospital Mailing Address
City
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
Zip
Hospital Telephone
Would the hospital like to participate in the FFY 2023 DSH program?
Yes
No
Must select Yes or No.
Would the hospital like to participate in the DY12 UC program?
Yes
No
Must select Yes or No.
Note: The Primary Application Contact and Primary Hospital Contact MUST be a different individual.
The Primary Application Contact, this person is authorized to act as a liaison between the hospital and HHSC.
(This person can be a contractor.)
Primary Application Contact Name
Primary Application Contact Telephone
Primary Application Contact Email
example: first.last@hosp.com
Please enter a valid email address.
Note: The Secondary Application Contact and Primary Hospital Contact MUST be a different individual.
Secondary Application Contact, the person designated to complete the DSH/UC Application on behalf of the Primary Hospital Contact.
(This person can be a contractor.)
Secondary Application Contact Name
Secondary Application Contact Telephone
Secondary Application Contact Email
example: first.last@hosp.com
Please enter a valid email address.
Is the hospital primary contact a CEO or CFO?
  CEO
  CFO
Must select CEO or CFO
Primary Hospital Contact, the person requesting the DSH/UC Application and that can make decisions on the hospital's behalf
(this person cannot be a contractor and is usually the hospital's CEO or CFO.)
Hospital CEO Name
Hospital CEO Telephone
Hospital CEO Email
Please enter a valid email address.
Primary Hospital Contact, the person requesting the DSH/UC Application and that can make decisions on the hospital's behalf
(this person cannot be a contractor and is usually the hospital's CEO or CFO.)
Hospital CFO Name
Hospital CFO Telephone
Hospital CFO Email
Please enter a valid email address.
Additional Contacts 1-3 please include representatives related to qualification and/or people who interact with HHSC during the Payments Cycle.
Contact 1 Name
Contact 1 Email
Please enter a valid email address.
Contact 2 Name
Contact 2 Email
Please enter a valid email address.
Contact 3 Name
Contact 3 Email
Please enter a valid email address.
Please verify all data before submitting.