CSHCN Services Program 2010 >Forms

Forms

Note: Forms printed from the TMHP website at www.tmhp.com will print with larger text than the forms in this appendix.

Benefit Codes: Home Health DME providers must enter Benefit Code: DM3 on all authorization requests and claims. All other providers, including regular DME, use Benefit Code: CSN.

Prior authorization for:

Additional Nutritional Assessment, Counseling, and Products Form and Instructions B-3

Apnea Monitor Form and Instructions B-6

Augmentative Communication Devices (ACDs) Form and Instructions B-10

Chest Physiotherapy Devices Form and Instructions B-15

Dental or Orthodontia Services Form and Instructions B-19

Diapers, Pull-ups, Briefs, or Liners Form and Instructions B-23

Durable Medical Equipment (DME) Form and Instructions B-26

External Insulin Pump Form and Instructions B-35

Hospice Services Form and Instructions B-37

Inpatient Psychiatric Care Form and Instructions B-40

Inpatient Hospital Admission-For Use by Facilities Only Form and Instructions B-43

Inpatient Rehabilitation Admission Form and Instructions B-48

Medical Foods Form and Instructions B-53

Omalizumab Form and Instructions B-56

Palivizumab (Synagis) Form and Instructions B-59

Pulse Oximeter Devices Form and Instructions B-63

Renal Dialysis Treatment Form and Instructions B-66

Respiratory Care-Certified Respiratory Care Practitioner (CRCP) Form and Instructions B-69

Stem Cell or Renal Transplant Form and Instructions B-71

Inpatient Surgery-For Surgeons Only Form and Instructions B-75

Outpatient Surgery-For Outpatient Facilities and Surgeons Form and Instructions B-78

Authorization for:

Hemophilia Blood Factor Products Form and Instructions B-82

Non-Face-to-Face Clinician-Directed Care Coordinated Services Form and Instructions B-85

Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face
Clinician-Directed Care Coordinated Services B-89

Extension of Outpatient Therapy (TP2) Form and Instructions B-91

Initial Outpatient Therapy (TP1) Form and Instructions B-95

Authorization and Prior Authorization Request Form and Instructions B-98

Criteria documentation for:

Criteria for Dental Therapy Under General Anesthesia B-101

Policy About the Criteria for Dental Therapy Under General Anesthesia, Attachment 1 B-103

Documentation of Receipt B-104

Documentation of Receipt (Spanish) B-105

Home Health (Skilled Nursing) Referral and Treatment Plan Form and Instructions B-106

Instructions for Physician/Dentist Assessment Form B-110

Instructions for Physician/Dentist Assessment Form (Spanish) B-111

Physician/Dentist Assessment Form B-112

Reimbursement Request for Transportation of the Remains of Deceased Clients B-114

Vision Care Eyeglass Client Certification Form B-115

Vision Care Eyeglass Client Certification Form (Spanish) B-116

Wheelchair Seating Evaluation Form and Instructions B-117

Provider forms for:

Claim Status Inquiry (CSI) Authorization B-127

Electronic Funds Transfer (EFT) Notification B-128

Electronic Remittance and Status (ER&S) Agreement B-130

Instructions for Completing the Provider Information Change Form B-132

Provider Information Change Form B-133

Refund Information Form B-134

Tort Response Form B-135

Department of State Health Services Form to Release CSHCN Services Program
Claims History B-136

Department of State Health Services Form to Release CSHCN Services Program
Claims History (Spanish) B-137