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5.1.4 Prior Authorization Requests for Clients with Medicare/Medicaid
If a client's primary coverage is Medicare, providers must always confirm with Medicare whether a service is a Medicare benefit for the client.
If a service that requires prior authorization from Medicaid is a Medicare benefit and Medicare approves the service, prior authorization from TMHP is not required for reimbursement of the coinsurance or deductible. If Medicare denies the service, then prior authorization is required. TMHP must receive a prior authorization request within 30 days of the date of Medicare's final disposition. The Medicare Remittance Advice and Notification (MRAN) that contains Medicare's final disposition must accompany the prior authorization request.
If a service requires prior authorization through Medicaid and the service is not a benefit of Medicare, providers may request prior authorization from TMHP before receiving the denial from Medicare.
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