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43.4.3.3 Prior Authorization Requirements
Non-face-to-face clinician directed care coordination services require prior authorization. Prior authorization is a condition for reimbursement; it is not a guarantee of payment. Providers must submit a request for prior authorization within seven business days of the date of service. Prior authorization is limited to a maximum of six months. Prior authorization is required to recertify the client for additional six-month periods and requires submission of a new request with documentation supporting medical necessity for ongoing services.
Prior authorization for an initial non-face-to-face clinician-directed care coordination requires documentation of at least one covered face-to-face inpatient or outpatient E/M visit by the clinician directing the care coordination during the six months preceding the provision of the first non-face-to-face care coordination service.
Prior authorization for subsequent non-face-to-face clinician directed care coordination services requires at least one covered face-to-face inpatient or outpatient E/M visit by the clinician directing the care coordination during the previous 12 months or more frequently as indicated by the client's condition.
Prior authorization of THSteps-CCP services may be requested in writing by completing a THSteps-CCP Prior Authorization Request Form, attaching the necessary supportive documentation as detailed below, and mailing or faxing it to the TMHP-CCP department:
Texas Medicaid & Healthcare Partnership
Comprehensive Care Program
PO Box 200735
Austin, TX 78720-0735
Fax: 1-512-514-4212
For prior authorization to be considered, clients must require complex and multidisciplinary care modalities involving regular clinician development and/or revision of care plans, review of subsequent reports of client status, and review of related laboratory and other studies.
• Medically complex: The health care needed by a Medicaid client achieves the designation of medically complex when the approved plan of care (POC) necessitates a clinical professional practicing within the scope of his or her license and in the context of a medical home to coordinate ongoing treatment to ensure its safe and effective delivery. The diagnosis must be covered under the Texas Medicaid Program and be characterized by one of the following:
•Significant and interrelated disease processes that involve more than one organ system (including behavioral health diagnoses) and require the services of two or more licensed clinical professionals, specialists, or subspecialists.
•Significant physical or functional limitations that require the services of two or more therapeutic or ancillary disciplines, including, but not limited to, nursing, nutrition, OT, PT, ST, orthotics, and prosthetics.
•Significant physical, developmental, or behavioral impairment that requires the integration of two or more medical and/or community-based providers, including, but not limited to, educational, social, and developmental professionals, that impact the care of the client.
•Multidisciplinary Care: Care is multidisciplinary when the medically necessary covered services of an approved POC include the need to coordinate the assessment, treatment, and/or services of a Medicaid-enrolled clinical provider with two or more additional medical, educational, social, developmental, or other professionals impacting the health care of the client.
Documentation of the following components must be submitted with the authorization form to obtain an initial authorization or renewal:
•A current medical summary, encompassing all disciplines and all aspects of the client's care, and containing key information about the client's health, e.g., conditions, complexity, medications, allergies, past surgical procedures, etc.
•A current list of the main concerns/issues/problems as well as key strengths/assets and the related current clinical information including a list of all diagnoses with ICD-9-CM diagnosis codes.
•Planned action steps/interventions to address the concerns and to sustain/build strengths, with the expected outcomes.
•Disciplines involved with the client's care and how the multiple disciplines will work/are working together to meet the client's need. Providers should explain how the multidisciplinary approach will/do benefit the client's needs.
•Short-term and long-term goals with timeframes.
The supporting documentation can be any of the following:
•A formal written care plan.
•Progress note detailing the care coordination planning.
•A letter of medical necessity detailing the care plan oversight and care coordination.
Prior authorization is effective for care coordination services provided over a period of six months. Clinicians must submit a revised care plan for subsequent periods of prior authorization.
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