TMPPM 2011 > Children's Services Handbook > Medicaid Children's Services Comprehensive Care Program (CCP) > CCP Overview > Prior Authorization and Documentation Requirements

2.2.4 Prior Authorization and Documentation Requirements

Prior authorization is a condition for reimbursement; it is not a guarantee of payment. A prior authorization number (PAN) is a TMHP-assigned number establishing that a service or supply has been determined to be medically necessary and for which FFP is available. It is each provider's responsibility to check the client's Medicaid Identification (Form H3087) at the time each service is provided to verify eligibility. Any service provided while the client is not eligible cannot be reimbursed by TMHP. The responsibility for payment of services is determined by private arrangements made between the provider and client.

Prior authorization of CCP services may be requested in writing by completing the appropriate request form, attaching any necessary supportive documentation, and mailing or faxing it to the TMHP-CCP department. Prior authorization may also be requested through the TMHP website. (Providers can refer to subsection 5.4.1, "Prior Authorization Requests Through the TMHP Website" in Section 5, "Prior Authorization" (Vol. 1, General Information) for additional information to include, mandatory documentation, and retention requirements). All requested information on the form must be completed, or the request is returned to the provider. Incomplete forms are not accepted. If prior authorization is granted, the potential service provider (such as the DME supplier, pharmacy, registered nurse (RN), or physical therapist) receives a letter that includes the PAN, the procedures prior authorized, and the length of the authorization. Providers are notified in writing when additional information is needed to process the request for services.

Written requests for prior authorization are mandatory for the following services:

•The purchase of apnea monitors and the rental of apnea monitors for clients who are 5 months of age and older or after an initial two months of rental

•Diapers, wipes, and underpads for clients who are birth through 3 years of age

•Customized and noncustomized DME not authorized under Texas Medicaid (Title XIX) Home Health Services

•Formula for a client who is birth through 20 years of age if the client does not have a gastrostomy (G-tube)/jejunostomy or nasogastric tube or a metabolic disorder

•Inpatient freestanding psychiatric services

•Inpatient freestanding rehabilitation services

•Gastrostomy buttons (G-buttons) not authorized under Texas Medicaid (Title XIX) Home Health Services

•Non-face-to-face clinician-directed care coordination services

•Orthotics and prosthetics

•PDN

•PCS-Prior authorization requests for PCS services can only be submitted by DSHS. Providers can refer to subsection 2.8, "Personal Care Services (PCS) (CCP)" in this handbook for the authorization criteria.

•OT, PT, ST services

•TPN

Providers must submit a CCP Prior Authorization Request Form and documentation to support medical necessity to the CCP department before providing services. Providers must submit the CCP Prior Authorization Request Form when requesting a medically necessary service if the service is not addressed in the Texas Medicaid Provider Procedures Manual and the client is 20 years of age or younger.

Important: Documentation to support medical necessity of the service, equipment, or supply (such as a prescription, letter, or medical records) must be current, signed, and dated by a physician (M.D. or D.O.) before services are performed. Providers must keep the information on file.

Refer to: CCP provider-specific sections for prior authorization requirements of specific services.