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Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook
Table of Contents
1. General Information MD-13
2. Chiropractic Manipulative Treatment (CMT) MD-13
2.1 Enrollment MD-13
2.2 Services/Benefits, Limitations and Prior Authorization MD-14
2.2.1 Prior Authorization MD-15
2.3 Documentation Requirements MD-15
2.4 Claims Filing and Reimbursement MD-15
2.4.1 Claims Information MD-15
2.4.2 Reimbursement MD-16
3. Certified Registered Nurse Anesthetist (CRNA) MD-16
3.1 Enrollment MD-16
3.2 Services/Benefits, Limitations and Prior Authorization MD-16
3.2.1 Epidural, Blood Patch MD-17
3.2.2 Prior Authorization MD-17
3.3 Documentation Requirements MD-17
3.4 Claims Filing and Reimbursement MD-17
3.4.1 Claims Information MD-17
3.4.1.1 Interpreting the R&S Report MD-17
3.4.2 Reimbursement MD-17
3.4.3 Non-Time-Based Units or Flat Fees MD-18
4. Genetic Services MD-18
4.1 Enrollment MD-18
4.1.1 Geneticists MD-18
4.2 Services/Benefits, Limitations and Prior Authorization MD-19
4.2.1 Geneticist Benefits MD-19
4.2.1.1 Genetic Evaluation and Counseling MD-20
4.2.2 Prior Authorization MD-20
4.3 Documentation Requirements MD-20
4.4 Claims Filing and Reimbursement MD-20
4.4.1 Claims Information MD-20
4.4.2 Reimbursement MD-21
5. Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) MD-21
5.1 Enrollment MD-21
5.1.1 Enrollment in Texas Health Steps (THSteps) MD-22
5.2 Services/Benefits, Limitations and Prior Authorization MD-22
5.2.1 Prior Authorization MD-22
5.3 Documentation Requirements MD-22
5.4 Claims Filing and Reimbursement MD-23
5.4.1 Claims Information MD-23
5.4.2 Reimbursement MD-23
6. Physician MD-23
6.1 Enrollment MD-23
6.1.1 Physicians and Doctors MD-23
6.1.2 Comprehensive Health Center (CHC) MD-24
6.2 Services/Benefits, Limitations, and Prior Authorization MD-24
6.2.1 Supervision MD-24
6.2.1.1 Teaching Attending Physician and Resident Physician MD-25
6.2.2 Substitute Physician MD-26
6.2.3 Physician Assistants (PAs), NPs, CNSs, and Certified Nurse-Midwives (CNMs) MD-27
6.3 Procedures and Services MD-27
6.3.1 Aerosol Treatment MD-27
6.3.2 Allergy Services MD-28
6.3.2.1 Allergy Immunotherapy MD-28
6.3.2.1.1 Prior Authorization for Allergy Immunotherapy MD-28
6.3.2.1.2 Limitations of Allergy Immunotherapy MD-28
6.3.2.2 Allergy Testing MD-29
6.3.2.2.1 RAST/MAST Tests MD-30
6.3.3 Nonemergency Ambulance Transport Services MD-30
6.3.4 Anesthesia MD-31
6.3.4.1 Anesthesia for Sterilization MD-31
6.3.4.2 Anesthesia for Labor and Delivery MD-31
6.3.4.3 Anesthesia Provided by the Surgeon (Other Than Labor and Delivery) MD-32
6.3.4.4 Complicated Anesthesia MD-32
6.3.4.5 Multiple Procedures MD-32
6.3.4.6 Services Incidental to Surgery and/or Anesthesia MD-32
6.3.4.7 Medical Direction by an Anesthesiologist MD-33
6.3.4.8 Monitored Anesthesia Care MD-34
6.3.4.9 Reimbursement Methodology MD-34
6.3.4.10 Anesthesia Modifiers MD-35
6.3.4.10.1 State-Defined Modifiers MD-36
6.3.4.10.2 Modifier Combinations MD-36
6.3.4.11 Prior Authorization for Anesthesia MD-37
6.3.4.12 Claim Filing MD-37
6.3.4.13 Anesthesia (General) for THSteps Dental MD-37
6.3.5 Abdominal Aortic Aneurysm Screening MD-37
6.3.6 Bariatric Surgery MD-37
6.3.6.1 Prior Authorization for Bariatric Surgery MD-38
6.3.7 Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of Bladder Cancer MD-40
6.3.8 Behavioral Health Services MD-40
6.3.9 Biopsy MD-40
6.3.10 Blepharoplasty Procedures MD-41
6.3.11 Cancer Screening and Testing MD-41
6.3.11.1 Medicaid for Breast and Cervical Cancer (MBCC) MD-41
6.3.11.2 Breast Cancer (BRCA) Screening MD-42
6.3.11.2.2 Prior Authorization for Gene Mutation Analysis MD-43
6.3.11.2.3 Retroactive Authorization MD-44
6.3.11.2.4 Mammography (Screening and Diagnostic Studies of the Breast) MD-44
6.3.11.2.5 Prognostic Breast and Gynecological Cancer Studies MD-45
6.3.11.3 Colorectal Cancer Screening MD-46
6.3.11.3.1 Prior Authorization for Colorectal Screening MD-47
6.3.11.4 Genetic Testing for Colorectal Cancer MD-47
6.3.11.4.1 Prior Authorization for Genetic Testing for Colorectal Cancer MD-48
6.3.11.4.2 Testing for Familial Adenomatous Polyposis MD-48
6.3.11.4.3 Hereditary Nonpolyposis Colorectal Cancer (HNPCC) MD-49
6.3.12 Capsulotomy MD-49
6.3.13 Casting, Splinting, and Strapping MD-49
6.3.14 Cardiopulmonary Resuscitation (CPR) MD-51
6.3.15 Chemotherapy MD-51
6.3.15.1 Chemotherapy Procedure Codes MD-51
6.3.16 Closure of Wounds MD-52
6.3.17 Cochlear Implants MD-53
6.3.18 Continuous Glucose Monitoring (CGM) MD-53
6.3.18.1 Prior Authorization for Continuous Glucose Monitoring MD-54
6.3.19 Developmental and Neurological Assessment and Testing MD-54
6.3.19.1 Assessment of Aphasia MD-55
6.3.19.2 Developmental Screening MD-55
6.3.19.3 Developmental Testing MD-55
6.3.19.4 Neurobehavioral Testing MD-56
6.3.19.5 12-Hour Limitation for Procedure Codes 96110, 96111, and 96116 MD-58
6.3.20 Diagnostic Tests MD-59
6.3.20.1 Ambulatory Blood Pressure Monitoring MD-59
6.3.20.2 Ambulatory Electroencephalogram (Ambulatory EEG) MD-60
6.3.20.3 Bone Marrow Aspiration, Biopsy MD-60
6.3.20.4 Cytopathology Studies-Other Than Gynecological MD-60
6.3.20.5 Echoencephalography MD-60
6.3.20.6 Electrocardiogram (EKG) MD-61
6.3.20.7 Electrodiagnostic (EDX) Testing MD-63
6.3.20.7.1 Electromyography (EMG) MD-64
6.3.20.7.2 Nerve Conduction Studies (NCS) MD-65
6.3.20.7.3 Documentation Requirements for EDX Testing MD-66
6.3.20.7.4 Prior and Retrospective Authorization for EDX Testing MD-67
6.3.20.8 Esophageal pH Probe Monitoring MD-68
6.3.20.9 Helicobacter Pylori (H. Pylori) MD-68
6.3.20.10 Myocardial Perfusion Imaging MD-69
6.3.20.11 Pediatric Pneumogram MD-70
6.3.21 Doppler Studies MD-70
6.3.22 Endoscopies MD-72
6.3.23 Extracorporeal Membrane Oxygenation (ECMO) MD-72
6.3.24 Family Planning MD-73
6.3.25 Gynecological Health Services MD-73
6.3.26 Hospital Visits MD-73
6.3.27 Hyperbaric Oxygen Therapy (HBOT) MD-74
6.3.28 Ilizarov Device and Procedure MD-76
6.3.29 Immunization Guidelines and Administration MD-76
6.3.29.1 Administration Fee MD-76
6.3.29.2 Documentation MD-77
6.3.29.3 Vaccine Adverse Event Reporting System (VAERS) MD-77
6.3.30 Immunizations for Clients Birth through 20 Years of Age MD-77
6.3.30.1 Vaccine Coverage Through the TVFC Program MD-78
6.3.30.2 Vaccine and Toxoid Procedure Codes MD-79
6.3.31 Immunizations for Clients Who Are 21 Years of Age or Older MD-82
6.3.31.1 Human Rabies Vaccine Supply MD-84
6.3.31.1.1 Obtaining Rabies Vaccine and HRIG from DSHS for PEP Use MD-84
6.3.32 Medications - Injectable MD-85
6.3.32.1 Injection Administration MD-87
6.3.32.2 Billing for Injectable Medications MD-88
6.3.32.3 Unit Calculations for Billing Drugs MD-88
6.3.32.4 Abatacept (Orencia) MD-89
6.3.32.4.1 Prior Authorization for Abatacept (Orencia) MD-89
6.3.32.5 Alatrofloxacin Mesylate (Trovan) MD-89
6.3.32.6 Alglucosidase Alfa (Myozyme) MD-90
6.3.32.6.1 Prior Authorization for Alglucosidase Alfa (Myozyme) MD-90
6.3.32.7 17-Alpha Hydroxyprogesterone Caproate MD-90
6.3.32.8 Amifostine MD-90
6.3.32.9 Antibiotics and Steroids MD-92
6.3.32.10 Antihemophilic Factor MD-92
6.3.32.11 Botulinum Toxin Type A MD-93
6.3.32.12 Chelating Agents MD-93
6.3.32.12.2 Edetate calcium disodium MD-93
6.3.32.12.3 Deferoxamine mesylate (Desferal) MD-93
6.3.32.12.4 Edetate disodium MD-94
6.3.32.13.1 Prior Authorization for Clofarabine MD-94
6.3.32.14 Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim) MD-94
6.3.32.15 Hematopoietic Injections MD-96
6.3.32.15.1 Epoetin Alfa (EPO) MD-97
6.3.32.15.2 Darbepoetin Alfa MD-97
6.3.32.16 Gamma Globulin/Immune Globulin MD-98
6.3.32.17 Hormone Injections MD-98
6.3.32.17.1 Prior Authorization for Growth Hormone MD-99
6.3.32.18 Injectable Contraceptives MD-99
6.3.32.19 Immunosuppressive Drugs MD-99
6.3.32.21 Iron Injections MD-101
6.3.32.21.2 Sodium Ferric Gluconate Complex in Sucrose (Ferrlecit) MD-102
6.3.32.21.3 Iron Sucrose (Venofer) MD-102
6.3.32.22 Joint Injections and Trigger Point Injections MD-102
6.3.32.23 Leuprolide Acetate (Lupron Depot) MD-103
6.3.32.24.1 Prior Authorization for Omalizumab MD-103
6.3.32.26 Implantable Infusion Pumps MD-104
6.3.32.26.1 Prior Authorization for Implantable Infusion Pumps MD-105
6.3.32.26.2 Implantation of Catheters, Reservoirs, and Pumps MD-105
6.3.32.27 Trastuzumab MD-106
6.3.32.27.1 Prior Authorization for Trastuzumab MD-106
6.3.33 Medications - Oral MD-106
6.3.34 Laboratory Services MD-107
6.3.34.1 THSteps Laboratory Services MD-107
6.3.34.2 Laboratory Handling Fee MD-107
6.3.34.3 Blood Counts MD-108
6.3.34.4 Clinical Lab Panel Implementation MD-108
6.3.34.5 Clinical Pathology Consultations MD-108
6.3.34.6 Cytogenetics Testing MD-109
6.3.34.7 Maternal Serum Alpha-Fetoprotein (MSAFP) MD-111
6.3.35 Lung Volume Reduction Surgery (LVRS) MD-111
6.3.35.1 Prior Authorization for Lung Volume Reduction Surgery MD-112
6.3.35.1.1 Noncovered Conditions MD-113
6.3.36 Mastectomy and Breast Reconstruction MD-114
6.3.37 Neurostimulators MD-115
6.3.37.1 Prior Authorization for Neurostimulator MD-115
6.3.37.2 Neuromuscular Electrical Stimulation (NMES) MD-116
6.3.37.2.2 NMES Purchase MD-116
6.3.37.2.3 NMES for Muscle Atrophy MD-116
6.3.37.2.4 NMES for Walking in Clients with Spinal Cord Injury (SCI) MD-116
6.3.37.3 Transcutaneous Electrical Nerve Stimulation (TENS) MD-117
6.3.37.3.2 TENS Purchase MD-118
6.3.37.4 NMES and TENS Garments MD-118
6.3.37.5 NMES and TENS Supplies MD-118
6.3.37.6 Dorsal Column Neurostimulator (DCN) MD-119
6.3.37.6.1 Prior Authorization for Dorsal Column Neurostimulators MD-119
6.3.37.7 Intracranial Neurostimulators MD-119
6.3.37.7.1 Prior Authorization for Intracranial Neurostimulators MD-119
6.3.37.8 Percutaneous Electrical Nerve Stimulation (PENS) MD-120
6.3.37.8.1 Prior Authorization for PENS MD-120
6.3.37.9 Sacral Nerve Stimulators (SNS) MD-120
6.3.37.9.1 Prior Authorization SNS MD-120
6.3.37.10 Vagal Nerve Stimulators (VNS) MD-121
6.3.37.10.1 Prior Authorization VNS MD-121
6.3.37.11 Prior Authorization of Neurostimulator Devices Procedure Codes MD-121
6.3.37.12 Supplies for Neurostimulators MD-121
6.3.37.13 Electronic Analysis for Neurostimulators MD-121
6.3.37.14 Revision or Removal of Neurostimulator Devices MD-121
6.3.37.15 Noncovered Neurostimulator Services MD-122
6.3.38 Newborn Services MD-122
6.3.38.1 Attendance at Delivery MD-122
6.3.38.2 Circumcisions MD-122
6.3.38.3 Claims Filing Instructions and Eligibility Requirements MD-123
6.3.38.4 Potential SSI/Medicaid Eligibility for Premature Infants MD-124
6.3.38.5 Hospital Visits and Routine Care MD-124
6.3.38.6 Newborn Hearing Screening MD-128
6.3.38.7 Critical Care Services MD-128
6.3.39 Obstetrics and Prenatal Care MD-132
6.3.39.1 Birthing Center Deliveries MD-134
6.3.39.2 Home Deliveries MD-134
6.3.39.3 Amniocentesis, Cordocentesis, and Ultrasonic Guidance MD-134
6.3.39.4 External Cephalic Version MD-134
6.3.39.5 Fetal Fibronectin MD-135
6.3.39.6 Fetal Intrauterine Transfusion (FIUT) MD-135
6.3.39.7 Doppler Studies MD-135
6.3.39.8 Echocardiography MD-135
6.3.39.9 Obstetric Ultrasound MD-136
6.3.39.10 Prenatal Surveillance MD-136
6.3.39.11 Documentation Requirements for Diagnostic Studies MD-138
6.3.39.12 Required Screening of Pregnant Women for Syphilis, HIV, and Hepatitis B MD-138
6.3.39.12.2 Hepatitis B Screening MD-138
6.3.40 Occupational Therapy MD-139
6.3.41 Ophthalmology MD-139
6.3.41.1 Corneal Transplants MD-139
6.3.41.2 Eye Surgery by Laser MD-139
6.3.41.2.1 Prior Authorization for Surgically or Trauma-Induced Astigmatism MD-139
6.3.41.2.2 Other Eye Surgery Procedures MD-140
6.3.41.3 Eye Surgery by Incision MD-142
6.3.41.4 Intraocular Lens (IOL) MD-143
6.3.41.5 Intravitreal Drug Delivery System MD-143
6.3.41.6 Iridectomy, Iridotomy, and Trabeculectomy MD-143
6.3.41.7 Ophthalmological Services Billed With a Diagnosis of Cataract MD-144
6.3.42 Organ/Tissue Transplants MD-144
6.3.42.1 Heart Transplants MD-144
6.3.42.1.1 Prior Authorization for Heart Transplants MD-144
6.3.42.1.2 Guidelines for Coverage of a Heart Transplant MD-144
6.3.42.2 Intestinal Transplants MD-145
6.3.42.2.1 Prior Authorization for Intestinal Transplants MD-145
6.3.42.2.2 Guidelines for Coverage of an Intestinal Transplant MD-145
6.3.42.2.3 Other Limitations for Intestinal Transplants MD-146
6.3.42.3 Kidney Transplants MD-146
6.3.42.3.1 Prior Authorization for Kidney Transplants MD-146
6.3.42.3.2 Guidelines for Coverage of a Kidney Transplant MD-146
6.3.42.3.3 Other Limitations for Kidney Transplants MD-147
6.3.42.4 Liver Transplants MD-147
6.3.42.4.1 Prior Authorization for Liver Transplants MD-147
6.3.42.4.2 Guidelines for Coverage MD-147
6.3.42.5 Lung Transplants MD-148
6.3.42.5.1 Prior Authorization for Lung Transplants MD-148
6.3.42.5.2 Guidelines for Coverage of a Lung Transplant MD-149
6.3.42.6 Pancreas Transplant and Simultaneous Kidney-Pancreas Transplant MD-149
6.3.42.6.1 Prior Authorization for Pancreas Transplant/Simultaneous Kidney-Pancreas Transplant MD-149
6.3.42.6.2 Guidelines for Coverage of a Pancreas/Simultaneous Kidney-Pancreas Transplant MD-149
6.3.42.6.3 Pancreas Transplant Alone MD-149
6.3.42.6.4 Simultaneous Kidney-Pancreas Transplant MD-150
6.3.42.7 Stem Cell Transplants MD-151
6.3.42.7.1 Prior Authorization for Stem Cell Transplants MD-153
6.3.42.8 Organ Procurement MD-154
6.3.42.9 Prior Authorization for All Transplants MD-154
6.3.43 Orthognathic Surgery MD-155
6.3.43.1 Prior Authorization for Orthognathic Surgery MD-155
6.3.44 Osteogenic Stimulation MD-156
6.3.45 Osteopathic Manipulative Treatment (OMT) MD-156
6.3.46 Pain Management MD-157
6.3.46.1 Epidural and Subarachnoid Infusion (Not Including Labor and Delivery) MD-158
6.3.47 Pentamadine, Aerosol MD-158
6.3.48 Percutaneous Transluminal Coronary Interventions MD-159
6.3.49 Physical Therapy (PT) Services MD-159
6.3.50 Physician Evaluation and Management (E/M) Services MD-159
6.3.50.1 Office or Other Outpatient Hospital Services MD-159
6.3.50.1.1 New and Established Patient Services MD-159
6.3.50.1.2 Preventive Care Visits MD-161
6.3.50.1.3 Consultation Services MD-162
6.3.50.1.4 Services Outside of Business Hours MD-162
6.3.50.1.5 Observation Services MD-162
6.3.50.2 Domiciliary, Rest Home, or Custodial Care Services MD-163
6.3.50.3 E/M Emergency Department Services MD-163
6.3.50.4 Group Clinical Visits MD-165
6.3.50.4.1 Group Clinical Visits for Diabetes MD-166
6.3.50.4.2 Group Clinical Visits for Asthma MD-166
6.3.50.5 Home Services MD-167
6.3.50.6 Inpatient Hospital Services MD-167
6.3.50.6.1 Hospital Admissions, Initial Visits, and Subsequent Visits MD-167
6.3.50.6.2 Concurrent Care MD-168
6.3.50.6.3 Consultations MD-169
6.3.50.6.4 Critical Care MD-169
6.3.50.6.5 Hospital Discharge MD-171
6.3.50.6.6 Nursing Facility Services MD-172
6.3.50.7 Prolonged Physician Services MD-173
6.3.50.8 Referrals MD-173
6.3.50.8.1 Referral Requirements for Children with Disabilities MD-174
6.3.51 Physician Services in a Long Term Care (LTC) Nursing Facility MD-174
6.3.52 Podiatry and Related Services MD-174
6.3.52.1 Clubfoot Casting MD-174
6.3.52.2 Flat Foot Treatment MD-174
6.3.52.3 Routine Foot Care MD-174
6.3.53 Prostate Surgery MD-175
6.3.54 Radiation Therapy MD-175
6.3.54.1 Brachytherapy MD-176
6.3.54.1.1 Prior Authorization for Brachytherapy MD-176
6.3.54.1.2 Other Limitations on Brachytherapy MD-176
6.3.54.2 Procedure Code Limitations MD-177
6.3.54.3 Stereotactic Radiosurgery MD-179
6.3.54.3.1 Prior Authorization for Sterotactic Radiosurgery MD-179
6.3.54.3.2 Other Limitations on Stereotactic Radiosurgery MD-180
6.3.55 Radiology Services MD-180
6.3.55.1 Cardiac Blood Pool Imaging MD-181
6.3.55.2 Chest X-Rays MD-181
6.3.55.3 Diagnosis Requirements MD-184
6.3.55.4 Therapeutic Radiopharmaceuticals MD-184
6.3.55.4.1 Prior Authorization for Therapeutic Radiopharmaceuticals MD-184
6.3.55.4.2 Other Limitations on Therapeutic Radiopharmaceuticals MD-185
6.3.55.5 Magnetic Resonance Angiography (MRA) MD-185
6.3.55.6 Magnetic Resonance Imaging (MRI) MD-185
6.3.55.7 Technetium TC 99M MD-186
6.3.56 Reduction Mammaplasties MD-186
6.3.56.1 Prior Authorization for Reduction Mammaplasty MD-186
6.3.57 Renal Disease MD-187
6.3.57.1 Dialysis Patients MD-187
6.3.57.1.1 Physician Supervision of Dialysis Patients MD-187
6.3.57.2 Laboratory Services for Dialysis Patients MD-189
6.3.57.3 Self-Dialysis Patients MD-189
6.3.57.3.1 Physician Supervision MD-189
6.3.57.3.2 Initial Training MD-190
6.3.57.3.3 Subsequent Training MD-190
6.3.58 Respiratory Syncytial Virus (RSV) Prophylaxis MD-190
6.3.58.1 Benefits and Limitations MD-191
6.3.58.2 Prior Authorization Requirements MD-191
6.3.58.3 Obtaining Palivizumab MD-193
6.3.59 Sign Language Interpreting Services MD-194
6.3.60 Skin Therapy MD-195
6.3.61 Sleep Studies MD-197
6.3.62 Speech-Language Therapy MD-198
6.3.63 Surgery Billing Guidelines MD-198
6.3.63.1 Primary Surgery MD-198
6.3.63.2 Anesthesia Administered by Surgeon MD-198
6.3.63.3 Assistant Surgeon MD-198
6.3.63.4 Bilateral Procedures MD-199
6.3.63.5 Cosurgery MD-199
6.3.63.6 Global Fees MD-200
6.3.63.7 Global Surgery Concurrent Care MD-201
6.3.63.8 Multiple Surgeries MD-201
6.3.63.9 Office Procedures MD-201
6.3.63.10 Orthopedic Hardware MD-202
6.3.63.11 Second Opinions MD-202
6.3.64 Supplies, Trays, and Drugs MD-202
6.3.65 Telemedicine Services MD-203
6.3.65.1 Distant Site MD-203
6.3.65.2 Patient Site MD-204
6.3.66 Therapeutic Apheresis MD-204
6.3.67 Therapeutic Phlebotomy MD-206
6.3.68 Ventilation Assist and Management for the Inpatient MD-206
6.3.69 Wearable Cardiac Defibrillator (WCD) MD-206
6.3.69.1 Prior Authorization for Wearable Cardiac Defibrillator (WCD) MD-207
6.4 Doctor of Dentistry Practicing as a Limited Physician MD-209
6.4.1 Medicaid Managed Care Enrollment MD-209
6.4.2 Prior Authorization for General Dental Services Due to Life-Threatening Medical Condition MD-210
6.4.2.1 Guidelines for Requesting Mandatory Prior Authorization MD-210
6.4.3 Benefits and Limitations MD-211
6.4.3.1 Diagnosis Codes MD-211
6.4.3.2 Evaluation and Management Procedure Codes MD-212
6.4.3.3 Additional Payable Procedure Codes MD-212
6.4.3.4 Immune Globulin by a Doctor of Dentistry as a Limited Physician MD-214
6.4.3.5 Radiographs by a Doctor of Dentistry Practicing as a Limited Physician MD-215
6.4.3.6 Dental Anesthesia by a Doctor of Dentistry Practicing as a Limited Physician MD-215
6.5 Documentation Requirements MD-215
6.6 Claims Filing and Reimbursement MD-215
6.6.1 Claims Information MD-215
6.6.2 National Drug Codes (NDC) MD-216
6.6.3 Reimbursement MD-216
6.6.3.1 Anesthesia Reimbursement MD-217
7. Physician Assistant MD-217
7.1 Enrollment MD-217
7.2 Services/Benefits, Limitations and Prior Authorization MD-218
7.2.1 Prior Authorization MD-219
7.3 Documentation Requirements MD-219
7.4 Claims Filing and Reimbursement MD-219
7.4.1 Claims Information MD-219
7.4.2 Reimbursement MD-219
8. Claims Resources MD-221
9. Contact TMHP MD-221
10. Forms MD-222
MD.1 Abortion Certification Statements Form MD-223
MD.2 DME Certification and Receipt Form (3 pages) MD-224
MD.3 Hospital Report (Newborn Child or Children) (Form 7484) MD-227
MD.4 Hysterectomy Acknowledgment Form MD-228
MD.5 Medicaid Certificate of Medical Necessity for Reduction Mammaplasty MD-229
MD.6 Nonemergency Ambulance Prior Authorization Request Form (2 Pages) MD-230
MD.7 Request for Extended Outpatient Psychotherapy/Counseling Form MD-232
MD.8 Special Medicaid Prior Authorization (SMPA) Request Form MD-233
MD.9 Sterilization Consent Form Instructions (2 pages) MD-234
MD.10 Sterilization Consent Form (English) MD-236
MD.11 Sterilization Consent Form (Spanish) MD-237
MD.12 Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Form MD-238
MD.13 Texas Medicaid Vendor Drug Program for Outpatient Pharmacies Synagis (Palivizumab) Prior Authorization Request & Prescription Form for 2009 MD-239
MD.14 THSteps Dental Mandatory Prior Authorization Request Form MD-240
MD.15 THSteps Dental Criteria for Dental Therapy Under General Anesthesia (2 pages) MD-241
11. Claim Form Examples MD-244
MD.16 Anesthesia MD-245
MD.17 Certified Nurse-Midwife (CNM) MD-246
MD.18 Certified Registered Nurse Anesthetist (CRNA) MD-247
MD.19 Chiropractic Services MD-248
MD.20 Dental (Doctor of Dentistry) MD-249
MD.21 Dialysis Training MD-250
MD.22 Genetics MD-251
MD.23 Radiation Therapy MD-252
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