7.5.15.3 Facility/Hospital ServicesRequests for prior authorization or notification of admissions for PCCM clients may be submitted via phone by calling the PCCM Inpatient Prior Authorization Department at 1-888-302-6167,faxed to 1-512-302-5039 using the PCCM Inpatient/Outpatient Authorization Form, or online through the TMHP website at www.tmhp.com. Online instructions for submitting authorization requests via the TMHP website can be found in the Help section at the bottom of the Prior Authorization screen.The provider must check the authorization request status before services are provided to confirm whether the authorization has been approved or denied. See "Prior Authorization Requests Through the TMHP Website" for additional information about mandatory documentation requirements and retention. All requests must include the following information:
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• Note: Submit medical records pertaining only to the service for the prior authorization that is being requested. If the provider's request is determined to be incomplete, the Inpatient Prior Authorization Department contacts the provider requesting the specific information needed to make the authorization determination and places the request in pending status. If the requested information is not received by the second business day, the information is requested again. If the information is not received by the fourth business day from the date the request was placed in pending status, the request is denied. A denial letter is sent to the facility and/or the requesting physician. When the requested information is received within four business days from the original pend date, the authorization is processed. For most admissions, a letter of notification/authorization is faxed to the requesting facility or the requesting physician once the determination is complete. For scheduled inpatient admissions, both the facility and the physician will receive faxed notification. Authorization is a condition of reimbursement. It is not a guarantee of payment. If the DRG submitted on a claim does not match the DRG on the authorization, one of the following will occur:
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• Claims are adjudicated based on the authorization that was completed at the time of the claim submission. To avoid a DRG mismatch and the denial of the claim when there is a change to an existing authorization (e.g., a change to the discharge date, diagnosis, DRG, or procedure), the facility is required to submit an updated PCCM Inpatient/Outpatient Authorization Form before the claim is submitted. The form can be submitted either by fax to 1-512-302-5039 or by contacting the Inpatient Prior Authorization Department at 1-888-302-6167. Notification of urgent and emergent admissions is only required before a claim is submitted. Providers are encouraged to submit the notification after DRG information is complete to avoid updating the DRG because of a DRG mismatch and a change to the admitting diagnosis. If the services rendered are different or more complex than the ones that were authorized, providers should contact the PCCM Inpatient Prior Authorization Department to update the authorization before the claim is submitted. For non-DRG facilities, the claim will pay at the lower number of inpatient days when the length of stay that is billed is different from the length of stay that was authorized. If there is a change to an existing authorization, providers should contact the PCCM Inpatient Prior Authorization Department with the update before the claim is submitted. |
Facility name and provider identifier.
