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 of the services 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 24.5, “Ambulatory Surgical Centers,” on page 24‑16.
Use:	The “CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons” form on page B-91.
Exception:	Does not include procedures listed in Section 4.3.1, “Services that Require Prior Authorization,” on page 4‑6.

Blood Pressure Devices, In Specific Instances
Refer to:	Chapter 11, “Blood Pressure Devices and Supplies,” on page 11‑1.
Use:	The “CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)” form on page B-28.

Botulinum Toxin (Type A and B)
Refer to:	Section 31.2.24.5, “Botulinum Toxin (Type A and Type B),” on page 31‑88.
Use:	The “CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons” form on page B-91.

Clinician-Directed Care Coordination Services
Refer to:	Section 31.2.12, “Clinician-Directed Care Coordination Services,” on page 31‑25.
Use:	The “CSHCN Services Program Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordinated Services” form on page B-97.

Durable Medical Equipment (DME)
Refer to:	Chapter 17, “Durable Medical Equipment (DME),” on page 17‑1.
Use:	The “CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)” form on page B-28.
Exception:	Custom DME and more complex equipment requires prior authorization.

Hemophilia Blood Factor Products
Refer to:	Section 31.2.8, “Blood Factor Products,” on page 31‑19.
Use:	The “CSHCN Services Program Authorization Request for Hemophilia Blood Factor Products” form on page B-94.

Home Health (Skilled Nursing Only) Up to 200 Hours Per Calendar Year
Refer to:	Chapter 22, “Home Health (Skilled Nursing) Care,” on page 22‑1.
Use:	The “CSHCN Services Program Home Health (Skilled Nursing) Referral and Treatment Plan” form on page B-118.

Nebulizers, In Specific Instances
Refer to:	Section 35.2.8, “Nebulizers,” on page 35‑9.
Use:	The “CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)” form on page B-28.

Outpatient Dental Surgical Procedures
Refer to:	Section 14.2.6, “Dental Treatment in Hospitals and ASCs,” on page 14‑36.
Use:	The “CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons” form on page B-91.
Use:	The “CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services” form on page B-20.
Use:	The “CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia” form on page B-111.

Outpatient Physical Therapy and Occupational Therapy Services
Refer to:	Section 30.2.2, “Physical Medicine, Physical Therapy (PT), and Occupational Therapy (OT),” on page 30‑3.
Use:	The “CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1)” form on page B‑107.
Use:	The “CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2)” form is located on page B‑103.

Outpatient Speech-Language Pathology Services (all services except initial evaluations)
Refer to:	Chapter 36, “Speech-Language Pathology (SLP) Services,” on page 36-1.
Use:	The “CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1)” form on page B‑107.
Use:	The “CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2)” form is located on page B‑103.