TMPPM 2008 > Provider Information > Claims Filing > Claims Information

   
 

5.1.2 Prior Authorization Requests Through the TMHP Website

Providers can submit prior authorization requests for the following services on the TMHP website.

Home Health:

Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies.

Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy.

Medicaid Certificate of Necessity for Chest Physiotherapy Device.

Statement for Initial Wound Therapy System In-Home Use.

Statement for Recertification of Wound Therapy System In-Home Use.

Wheelchair/Scooter/Stroller Seating Assessment (THSteps-CCP/Home Health Services).

Home Health Services Plan of Care (POC).

Primary Care Case Management (PCCM):

Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization.

Comprehensive Care Inpatient Psychiatric (CCIP):

Psychiatric Hospital Initial Admission Request.

Psychiatric Inpatient Extended Stay Request.

Comprehensive Care Program (CCP):

THSteps-CCP ECI Request for Initial/Renewal Outpatient Therapy

Request for Initial Outpatient Therapy.

Request for Extension of Outpatient Therapy.

Donor Human Milk Request.

Pulse Oximeter.

Wheelchair/Scooter/Stroller Seating Assessment (THSteps-CCP/Home Health Services).

Texas Medicaid Palivizumab (Synagis) Prior Authorization Request.

THSteps-CCP Prior Authorizations Request:

Apnea Monitor.

Bed/Crib.

Formula.

Total Parenteral Nutrition (TPN)/Hyperalimentation.

Private Duty Nursing.

Miscellaneous.

Ambulance:

Short-Term (1 to 60 days).

Long-Term (180 days).

Special Medical Prior Authorizations (SMPA):

Extended Outpatient Psychotherapy/Request.

Links to these new online functions are available from the "I would like to..." links located on the right-hand side of homepage at www.tmhp.com. Select Submit a prior authorization request to submit a new request or Search for/extend an existing prior authorization to check the status of or extend an authorization request that was previously submitted through the TMHP website.

The benefits of submitting authorizations on the TMHP website include:

Online editing to ensure that the required information is submitted correctly.

The authorization number is issued within seconds of submission and confirms that the authorization request was accepted. Providers must still check the status of authorization requests before they provide services to determine whether the authorization was approved or denied.

Notification of approvals and denials is available more quickly.

Online authorization requests, extensions, and status checks can be performed at the provider's convenience.

Instructions for submitting authorization requests on the TMHP website are located in the Help section at the bottom of the Prior Authorization page.

Prior authorizations that are submitted online will be processed using the same guidelines as authorizations submitted through existing channels, such as on paper, via fax, or by telephone.

Document Requirements and Retention

If the information provided in the online request is insufficient to support medical necessity, TMHP Prior Authorization staff may request providers to submit additional paper documentation to support the medical necessity of the service or services being requested for authorization.

Submission of prior authorization requests on the secure pages of the TMHP website does not replace adherence to and completion of the paper forms/documentation requirements outlined in the TMPPM and other publications.

Documentation requirements include, but are not limited to:

Completion and retention in the client's medical record of all required prior authorization forms (TMPPM, Appendix B) and documentation supporting medical necessity of the service requested.

Adherence to signature and date requirements for prior authorization forms and other required forms maintained in the client record. This includes:

Completion and signatures prior to requesting the authorization online.

Original handwritten signatures; computerized or stamped signatures are not accepted by the Texas Medicaid Program.

In addition, the printed copy of the Online Request Form must be maintained in the client's medical record.

Any mandatory requirement not present in the client's medical record subjects the associated services to recoupment.

Refer to: "General Medical Record Documentation Requirements" for further information.

Providers are required to register on the website and assign an administrator for each Texas Provider Identifier (TPI) and National Provider Identifier (NPI), if not already assigned. Users configured with administrator rights automatically have permission to submit prior authorization requests. The TPI administrator must assign submission privileges for non-administrator accounts. Billing services and clearinghouses are required to obtain access to protected health care information through the appropriate administrator of each TPI/NPI provider number for which they are contracted to provide services.

Acknowledgement Statement

Before submitting each prior authorization request, the provider and authorization request submitter must read, understand, and agree to the certification and terms and conditions of the prior authorization request.

The provider and authorization request submitter are both held accountable for their declarations when they acknowledge their agreement and consent. They acknowledge consent by checking the "We Agree" checkbox after reviewing the certification and terms and conditions.

Certification Statement:

"The Provider and Authorization Request Submitter certify that the information supplied on the prior authorization form and any attachments or accompanying information constitute true, correct, and complete information. The Provider and Authorization Request Submitter understand that payment of claims related to this prior authorization will be from Federal and State funds, and that falsifying entries, concealment of a material fact, or pertinent omissions may constitute fraud and may be prosecuted under applicable federal and/or state law. Fraud is a felony, which can result in fines or imprisonment."

"By checking `We Agree' you agree and consent to the Certification above and to the TMHP `Terms and Conditions.'"

Terms and Conditions:

"I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the States Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or U.S. Dept. of Health and Human Services may request. I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception of authorized deductible, coinsurance, co-payment or similar cost-sharing charge. I certify that the services listed above are/were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction."

"Notice: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim, based on information provided on the Prior Authorization form, will be from Federal and State funds, and that any false claims, statements or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State law."

Failure to provide true and accurate information, omit information, or provide notice of changes to the information previously provided may result in termination of the provider's Medicaid enrollment and/or personal exclusion from the Texas Medicaid Program.


Texas Medicaid & Healthcare Partnership
CPT only copyright 2007 American Medical Association. All rights reserved.
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