TMPPM 2010 > Nursing and Therapy
Services Handbook > Home Health Services For Nursing and Therapy > Services, Benefits, Limitations, and Prior Authorization > Prior Authorization

3.2.9 Prior Authorization

Prior authorization of initial coverage of home health services SN, HHA, OT, and PT for an eligible client can be obtained by calling the TMHP Contact Center Home Health Services line at 1-800-925-8957, by fax to 1-512-514-4209, or on the TMHP website at www.tmhp.com.

The following prior authorization requests can be submitted on the TMHP website at www.tmhp.com:

•Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form

•Home Health Services POC

Refer to: Subsection 5.3.1, "Prior Authorization Requests Through the TMHP Website" in Section 5, Prior Authorization (Vol. 1, General Information) for more information, including mandatory documentation requirements.

If a client's primary coverage is private insurance, and Medicaid is secondary, prior authorization is required for Medicaid reimbursement. If the primary coverage is Medicare, Medicare approves the service, and Medicaid is secondary, prior authorization is not required. TMHP will pay only the coinsurance and/or deductible. If Medicare denied the service, then Medicaid prior authorization is required. Contact Medicaid within 30 days of the date of Medicare's final disposition. The medicare remittance advice notice (MRAN) containing Medicare's final disposition must accompany the prior authorization request. If the service is a Medicaid-only service, prior authorization is required within three business days of the SOC date.

The provider is responsible for determining if eligibility is effective by using Automated Inquiry System (AIS) or an electronic eligibility inquiry through TMHP EDI gateway.

The provider must contact the TMHP Home Health Services Prior Authorization Department within three business days of the SOC for professional services or the DOS for DME/medical supplies to obtain prior authorization following the registered nurse's (RN) assessment/evaluation of the client in the home setting. When contacting TMHP by telephone for prior authorization, the nurse who made the initial assessment visit in the client's home must make this call to answer questions about the client's condition as it relates to the medical necessity.

If inadequate or incomplete information is provided or medical necessity is lacking, the provider will be requested to furnish additional documentation as required to make a decision on the request. Because it often must be obtained from the client's physician, providers have two weeks to submit the requested documentation. If the additional documentation is received within the two-week period, prior authorization can be considered for the original date of contact. If the additional documentation is received more than two weeks from the request for the documentation, prior authorization is not considered before the date the additional documentation is received. It is the DME/supplier/home health agency's responsibility to contact the physician to obtain the requested additional documentation.

TMHP Home Health Services toll-free number is 1-800-925-8957. The Home Health Services Prior Authorization Checklist is a useful resource for home health agency providers completing the prior authorization process. This optional form offers the nurse a detailed account of the client's needs when completed.

Refer to: Subsection 1.2.2, "Durable Medical Equipment (DME) and Supplies " in Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks) for DME/medical supplies prior authorization.

Subsection 3.4.2, "Medicaid Relationship to Medicare" of this handbook.

Client eligibility for Medicaid is for one month at a time. Providers should verify eligibility every month. Prior authorization does not guarantee payment.