CSHCN 2009 >4.3.1 Services that Require Prior Authorization

4.3.1 Services that Require Prior Authorization

The following is a list of many of the services that require prior authorization. The list below is not all-inclusive. Information about specific prior 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.

Anterior Temporal Lobectomies

Refer to: Section 29.2.5, "Anterior Temporal Lobectomy".

Use: The "CSHCN Services Program Prior Authorization Request for Inpatient Surgery-For Surgeons Only" form on page B-91.

Augmentative Communication Devices (ACDs)

Refer to: Chapter 10, "Augmentative Communication Devices (ACDs)".

Use: The "CSHCN Services Program Prior Authorization Request for Augmentative Communication Devices (ACDs)" form on page B-10.

Bone Marrow/Stem Cell Transplants (initial and one subsequent transplant)

Refer to: Section 29.2.38.1, "Renal (Kidney) Transplant".

Use: The "CSHCN Services Program Prior Authorization Request for Bone Marrow, Stem Cell, or Renal Transplant" form on page B-20.

Certified Respiratory Care Practitioner

Refer to: Chapter 13, "Certified Respiratory Care Practitioner (CRCP)".

Use: The "CSHCN Services Program Prior Authorization Request for Respiratory Care-Certified Respiratory Care Practitioner (CRCP)" form is located on page B-87.

Cleft/Craniofacial Surgical Procedures

Refer to: Section 29.2.35.12, "Cleft/Craniofacial Procedures".

Use: The "CSHCN Services Program Prior Authorization Request for Inpatient Surgery-For Surgeons Only" form on page B-91.

Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery-For Outpatient Facilities and Surgeons" form on page B-95.

Cranial Molding Devices (Dynamic Orthotic Cranioplasty [DOC™] only)

Refer to: Section 26.2.2, "Orthoses".

Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)" form on page B-36.

Custom (manual or powered) Wheelchair Purchases and Custom Seating Systems

Refer to: Section 17.3.17, "Wheelchairs".

Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)" form on page B-36.

Use: The "CSHCN Services Program Wheelchair Seating Evaluation Form," on page B-136.

Dental Procedures (some), Including Inpatient Admissions for Dental Surgical Procedures

Refer to: Chapter 14, "Dental".

Use: The "CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services" form on page B-26.

Use: The "CSHCN Services Program Prior Authorization Request for Inpatient Hospital Admission-For Use by Facilities Only" form on page B-56.

Diapers, Liners, and Pull-ups (or any combinations of these supplies)

Require prior authorization for quantities that exceed 300 per month.

Refer to: Chapter 18, "Expendable Medical Supplies".

Use: The "CSHCN Services Program Prior Authorization Request for Diapers, Pull-ups, or Liners" form on page B-30.

Home Health (Skilled Nursing) Services Over 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.

Hospice Services

Refer to: Chapter 21, "Hospice".

Use: The "CSHCN Services Program Prior Authorization Request for Hospice Services" form on page B-47.

Inpatient Admissions and Extensions

Refer to: Section 22.3, "Inpatient Services".

Use: The "CSHCN Services Program Prior Authorization Request for Inpatient Hospital Admission-For Use by Facilities Only" form on page B-56.

Inpatient Rehabilitation Admissions

Refer to: Section 22.3.1.2, "Inpatient Rehabilitation Services".

Use: The "CSHCN Services Program Prior Authorization Request for Inpatient Rehabilitation Admission" form on page B-62.

Medical Foods, In Specific Instances

Refer to: Section 24.2, "Medical Foods".

Use: The "CSHCN Services Program Prior Authorization Request for Medical Foods" form on page B-67.

More Than One Hour (Four Units) of Nutritional Assessments and Intervention per Rolling Year and More Than Two Nutritional Counseling Visits per Rolling Year

Refer to: Section 24.3, "Medical Nutritional Counseling Services".

Use: The "CSHCN Services Program Prior Authorization Request for Additional Nutritional Assessment, Counseling, and Products" form on page B-6.

Orthodontia

Refer to: Section 14.2.3, "Orthodontia Services".

Use: The "CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services" form on page B-26.

Pediatric Hospital Cribs and Tops

Refer to: Section 17.3.8, "Hospital Beds (Manual and Electric)".

Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)" form on page B-36.

Radiation Therapy Services (some), Including Proton- or Neutron-Beam Treatment Delivery, Intensity Modulated Radiation Therapy, and Stereotactic Radiosurgery

Refer to: Chapter 30, "Radiation Therapy Services".

Use: The "CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery-For Outpatient Facilities and Surgeons" form on page B-95.

Reduction Mammoplasties

Refer to: Section 29.2.35.13, "Reconstructive and Cosmetic Procedures".

Use: The "CSHCN Services Program Prior Authorization Request for Inpatient Surgery-For Surgeons Only" form on page B-91.

Renal Dialysis

Refer to: Chapter 31, "Renal Dialysis".

Use: The "CSHCN Services Program Prior Authorization Request for Renal Dialysis Treatment" form on page B-84.

Renal Transplants

Refer to: Section 29.2.38, "Transplants".

Use: The "CSHCN Services Program Prior Authorization Request for Bone Marrow, Stem Cell, or Renal Transplant" form on page B-20.

Rhizotomies