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6.12.1 Unbundled Services That Are Prior Authorized and Manually Priced Procedure Codes
Providers that submit prior authorization requests and claims to TMHP must:
• Unbundle any bundled procedure codes that have been submitted to the client's other insurance company.
•Itemize the rates.
If prior authorization has been obtained for services that use manually priced procedure codes, providers must submit claims for the services using the MSRP that was submitted with the authorization request and the following information that is listed on the authorization letter:
•The authorization number
•The provider identifier
•The procedure codes
•The dates of service
•The types of service
•The required modifiers
If the authorization letter shows itemized details, the claim must include all rendered services as they are itemized on the authorization letter and the MSRP rate for each of those services. The procedure codes and MSRP rates that are detailed on the claim must match the procedure codes that are detailed in the authorization letter and the MSRP rates that were submitted with the authorization request. Claims processing and payment may be delayed if there is not an exact match between the detailed information on the authorization letter, the approved authorization, and the information that was submitted on the claim.
Important: For appropriate processing and payment, the Pay Price that is indicated on the authorization letter should not be submitted on the claim.
Prior authorization is a condition of reimbursement; it is not a guarantee of payment.
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