TMPPM 2011 > Volume 1, General Information > Section 8: Managed Care > PCCM > Outpatient Prior Authorization Process > Requesting Prior Authorization

8.6.18.1 Requesting Prior Authorization

Requests for prior authorization of outpatient services may be made by faxing a completed Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization Form to the Outpatient Prior Authorization Department at 1-512-302-5039, by calling 1-888-302-6167, or through the TMHP website at www.tmhp.com. Forms other than the PCCM Inpatient/Outpatient Authorization Form will not be accepted for outpatient prior authorizations or updates.

Refer to: Subsection 5.4.1, "Prior Authorization Requests Through the TMHP Website" in Section 5, "Prior Authorization" (Vol. 1, General Information).

The request must include the following information:

•Facility name and provider identifier

•Client name, Medicaid number (PCN), and DOB

•Requesting (admitting) physician's name and provider identifier (if requesting authorization by paper)

Note: Online authorization requests submitted on the TMHP website require an NPI. TPIs can no longer be submitted for authorization requests through the TMHP website.

•Name of person completing form

•Date completed

•Telephone and fax number

•Admit date

•Diagnosis codes (primary, secondary, etc.)

•Procedure codes

•Clinical information to support medical necessity is required

If the prior authorization request is determined to be incomplete, the Outpatient Prior Authorization Department faxes the provider a letter requesting the specific information needed to make the prior authorization determination and places the request in pending status. At least two additional attempts to call or fax the provider to obtain this information will be made during the next four business days. If the requested information is not received by the fourth business day, a letter is sent to the client stating that the prior authorization request cannot be processed until the provider responds with the specific information necessary to complete the prior authorization request. This client letter is sent along with a copy of the initial letter to the provider that lists the specific information necessary to make the prior authorization determination. If the provider does not submit the information necessary to complete the prior authorization request within seven calendar days from the date the letter was sent to the client, a letter is sent to the provider and the client notifying them of the denial of service due to incomplete or missing information.

A letter of authorization determination is faxed to the requesting provider once the request is completed.

Authorization is a condition of reimbursement. It is not a guarantee of payment.

Claims are processed based on the authorization completed at the time of claim submission.

If there is a change in an existing authorization (i.e., change in diagnosis or change in procedure), the facility or provider is required to submit an updated Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization Form with clinical documentation supporting the change or contact the Outpatient Prior Authorization Department with the update prior to claim submission to avoid claim denial.

Providers performing urgent or emergent outpatient procedures that require authorization must contact the PCCM Outpatient Prior Authorization Department within seven calendar days to obtain the authorization.