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4.2.1 Services that Require Authorization
The following is a list of many of the services that require authorization. The list below is not all-inclusive. Information about specific authorization requirements for each service that is a benefit of the CSHCN Services Program is included in the chapter for each service. Refer to the specific provider sections in this manual or call TMHP at 1-800-568-2413 for more information.
Ambulatory Surgeries Performed at a Freestanding Facility or as Outpatient Hospital Day Surgeries
Refer to: Section 22.5, "Ambulatory Surgical Centers". Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery-For Outpatient Facilities and Surgeons" form on page B-95. Exception: Does not incluUsechapnumde procedures listed under Section 4.3.1, "Services that Require Prior Authorization".
Blood Pressure Devices, In Specific Instances
Refer to: Chapter 11, "Blood Pressure Devices and Supplies,". Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)" form on page B-36.
Botulinum Toxin (Type A and B)
Refer to: Section 29.2.24.3, "Botulinum Toxin (Type A and Type B)". Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery-For Outpatient Facilities and Surgeons" form on page B-95.
Clinician-Directed Care Coordination Services
Refer to: Section 29.2.12, "Clinician-Directed Care Coordination Services". Use: The "CSHCN Services Program Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordinated Services" form on page B-109.
Durable Medical Equipment (DME)
Refer to: Chapter 17, "Durable Medical Equipment (DME),". Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)" form on page B-36. Exception: Custo Indentem manual wheelchairs, all powered wheelchairs, custom seating systems, pediatric hospital cribs and tops, and other specified DME require prior authorization.
Hemophilia Supplies and Blood Factor Products
Refer to: Section 29.2.8, "Blood Factor Products". Use: The "CSHCN Services Program Authorization Request for Hemophilia Blood Factor Products" form on page B-105.
Home Health (Skilled Nursing Only) Up to 200 Hours Per Calendar Year
Refer to: Chapter 20, "Home Health (Skilled Nursing) Care,". Use: The "CSHCN Services Program Home Health (Skilled Nursing) Referral and Treatment Plan" form on page B-132.
Nebulizers, In Specific Instances
Refer to: Section 32.2.8, "Nebulizers". Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)" form on page B-36.
Orthotics and Prosthetics
Refer to: Chapter 26, "Orthotic and Prosthetic Devices,". Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)" form on page B-36.
Outpatient Dental Surgical Procedures
Refer to: Section 14.2.6, "Dental Treatment in Hospitals and Ambulatory Surgical Centers". Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery-For Outpatient Facilities and Surgeons" form on page B-95. Use: The "CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services" form on page B-26. Use: The "CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia" form on page B-122.
Outpatient Physical Therapy and Occupational Therapy Services
Refer to: Section 28.2.2, "Physical Medicine, Physical Therapy (PT), and Occupational Therapy (OT)". Use: The "CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1)" form on page B-119. Use: The "CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2)" form is located on page B-115.
Prescription Shoes
Refer to: Section 26.2.3, "Prescription Shoes and Lifts". Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)" form is located on page B-36.
Speech-Language Pathology Services (all services except initial evaluations)
Refer to: Chapter 33, "Speech-Language Pathology (SLP) Services". Use: The "CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1)" form on page B-119. Use: The "CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2)" form is located on page B-115.
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