TMPPM 2008 > Provider Information > Managed Care > PCCM

7.5.16 Outpatient Prior Authorization Process

The following outpatient procedures require prior authorization:

•Computed tomography (CT) imaging.

•Computed tomography angiography (CTA).

•Magnetic resonance imaging (MRI).

•Magnetic resonance angiography (MRA).

•All laser surgeries.

•Some endoscopic procedures.

•Some podiatry procedures.

•pH probe tests.

•Sleep studies.

•Some surgical procedures.

Prior authorization for clients with retroactive eligibility must be obtained by the PCCM provider within 95 days of the add date and before claims submission.

Refer to: "Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)" for more information about MRI/MRA and CT/CTA authorizations.

The following outpatient procedures do not require prior authorization:

•Anesthesia services (type of service 7).

•Surgeries performed on an outpatient emergent basis (retrospective authorization must occur for claims payment).

•Application/removal of casts, splints, or strapping (excluding podiatry office procedures and services).

•Burns - local treatment (does not include skin grafts or long-term wound care).

•Catheterization of blood vessels (excluding heart catheterizations) for diagnosis or therapy (includes venous access, puncture of shunt, etc.).

•Cholecystectomy.

•Circumcision, newborn and for phimosis (up to 21 years of age).

•Fractures/dislocations (closed or open treatment).

•Incision and drainage of abscesses.

•Injection procedures for radiology or in conjunction with surgical procedures.

•Intubation/tracheostomy tube changes.

•Polysomnography.

•Removal of foreign bodies.

•Removal of pressure equalization tubes with or without grafts.

•Repair of lacerations/wounds (includes the eye).

•Replacement of gastrostomy tubes.

•Replantation of digits.

•Sterilization procedures (male and female).

•Urodynamics.

•Esophageal manometry.

•Ultrasounds.

•Holter monitors.

•Tympanostomy.

•Tonsillectomy for client's under 12 years of age.

•Adenoidectomy for client's under 12 years of age.

•Bronchoscopy.

•Sigmoidoscopy.

•Proctosigmoidoscopy.

•Permanent removal of nail/nail matrix.

•Colonoscopy (except with endoscopic ultrasound exam or fine needle biopsy).

•Esophageal Endoscopy (except for ablation procedures).

•Appendectomy for ruptured appendix or incidental removal.

•Hernia repair (except initial repair under 5 years of age with strangulation or incarceration).

•Upper GI Endoscopy (except for drainage of psuedocyst or placement of gastrostomy tube).

Requesting Prior Authorization

Requests for prior authorization of outpatient services may be made by faxing a completed PCCM Inpatient/Outpatient Authorization Form to the Outpatient Prior Authorization Department at 1-512-302-5039, by calling 1-888-302-6167, or through the TMHP website at www.tmhp.com. Other forms will not be accepted for outpatient prior authorizations or updates.

Refer to: "Prior Authorization Requests Through the TMHP Website" for more information.

The request must include the following information:

•Facility name and provider identifier.

•Client name, Medicaid number (PCN), and date of birth.

•Requesting (admitting) physician's name and provider identifier.

•Name of person completing form.

•Date completed.

•Telephone and fax number.

•Admit date.

•Diagnosis codes (primary, secondary, etc.).

•Procedure codes.

•Clinical information to support medical necessity is required.

If the prior authorization request is determined to be incomplete, the Outpatient Prior Authorization Department faxes the provider a letter requesting the specific information needed to make the prior authorization determination and places the request in pending status. At least two additional attempts to call and/or fax the provider to obtain this information will be made during the next four business days. If the requested information is not received by the fourth business day, a letter is sent to the client stating that the prior authorization request cannot be processed until the provider responds with the specific information necessary to complete the prior authorization request. This client letter is sent along with a copy of the initial letter to the provider that lists the specific information necessary to make the prior authorization determination. If the provider does not submit the information necessary to complete the prior authorization request within seven calendar days from the date of the letter sent to the client, a letter is sent to the provider and the client notifying them of the denial of service due to incomplete or missing information.

A letter of authorization determination is faxed to the requesting provider once the request is completed.

Authorization is a condition of reimbursement. It is not a guarantee of payment.

Claims are processed based on the authorization completed at the time of claim submission.

If there is a change in an existing authorization (i.e., change in diagnosis or change in procedure), the facility/provider is required to submit an updated PCCM Inpatient/Outpatient Authorization Form with clinical documentation supporting the change or contact the Outpatient Prior Authorization Department with the update prior to claim submission to avoid claim denial.

Providers performing urgent or emergent outpatient procedures that require authorization must contact the PCCM Outpatient Prior Authorization Department within 7 calendar days to obtain the authorization.