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Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook
1. General Information MD-15
2. Chiropractic Manipulative Treatment (CMT) MD-16
2.1 Enrollment MD-16
2.2 Services, Benefits, Limitations and Prior Authorization MD-16
2.2.1 Prior Authorization MD-16
2.3 Documentation Requirements MD-17
2.4 Claims Filing and Reimbursement MD-17
2.4.1 Claims Information MD-17
2.4.2 Reimbursement MD-17
3. Certified Nurse Midwife (CNM) MD-18
3.1 Provider Enrollment MD-18
3.1.1 Enrollment in Texas Health Steps (THSteps) MD-18
3.2 Services, Benefits, Limitations, and Prior Authorization MD-18
3.2.1 Deliveries MD-18
3.2.2 Newborn Services MD-18
3.2.3 Prenatal and Postpartum Services MD-19
3.2.4 Laboratory and Radiology Services MD-19
3.2.5 Prior Authorization MD-19
3.2.6 Documentation Requirements MD-19
3.2.7 Claims Filing and Reimbursement MD-19
4. Certified Registered Nurse Anesthetist (CRNA) MD-20
4.1 Enrollment MD-20
4.2 Services, Benefits, Limitations and Prior Authorization MD-20
4.2.1 Prior Authorization MD-21
4.3 Documentation Requirements MD-21
4.4 Claims Filing and Reimbursement MD-21
4.4.1 Claims Information MD-21
4.4.1.1 Interpreting the R&S Report MD-21
4.4.2 Reimbursement MD-21
5. Geneticists MD-22
5.1 Enrollment MD-22
5.1.1 Geneticists MD-22
5.2 Services, Benefits, Limitations and Prior Authorization MD-22
5.2.1 Family History MD-23
5.2.2 Genetic Tests MD-23
5.2.3 Laboratory Practices MD-23
5.2.4 Genetic Counselors MD-24
5.2.5 Genetic Evaluation and Counseling by a Geneticist MD-24
5.2.6 Prior Authorization MD-24
5.3 Documentation Requirements MD-24
5.4 Claims Filing and Reimbursement MD-25
5.4.1 Claims Information MD-25
5.4.2 Reimbursement MD-25
6. Maternity Service Clinics (MSC) MD-25
6.1 Provider Enrollment MD-25
6.1.1 Physician Responsibility MD-26
6.1.2 Case Management Services to High-Risk Individuals MD-26
6.2 Services, Benefits, Limitations, and Prior Authorization MD-26
6.2.1 Initial Prenatal Care Visit Components MD-27
6.2.1.2 Physical Examination MD-27
6.2.1.3 Laboratory Tests MD-27
6.2.1.4 Assessment MD-28
6.2.1.6 Education and Counseling MD-28
6.2.2 Subsequent Prenatal Care Visits MD-28
6.2.2.1 Physical Examination MD-29
6.2.2.2 Laboratory Tests MD-29
6.2.3 Postpartum Care Visit MD-29
6.2.4 Prior Authorization MD-29
6.3 Documentation Requirements MD-29
6.4 Claims Filing and Reimbursement MD-29
7. Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) MD-30
7.1 Enrollment MD-30
7.1.1 Enrollment in Texas Health Steps (THSteps) MD-30
7.2 Services, Benefits, Limitations and Prior Authorization MD-31
7.2.1 Prior Authorization MD-31
7.3 Documentation Requirements MD-31
7.4 Claims Filing and Reimbursement MD-31
7.4.1 Claims Information MD-31
7.4.2 Reimbursement MD-32
8. Physician MD-32
8.1 Enrollment MD-32
8.1.1 Physicians and Doctors MD-32
8.2 Services/Benefits, Limitations, and Prior Authorization MD-32
8.2.1 Teaching Physician and Resident Physician MD-33
8.2.1.1 Teaching Physician Prerequisites MD-33
8.2.2 Substitute Physician MD-34
8.2.3 Aerosol Treatment MD-35
8.2.4 Allergy Services MD-35
8.2.4.1 Allergy Immunotherapy MD-36
8.2.4.1.1 Prior Authorization for Allergy Immunotherapy MD-36
8.2.4.1.2 Limitations of Allergy Immunotherapy MD-36
8.2.4.2 Allergy Testing MD-37
8.2.4.2.1 RAST/MAST Tests MD-39
8.2.4.2.2 Collagen Skin Test MD-39
8.2.4.2.3 Prior Authorization for Collagen Skin Tests MD-39
8.2.5 Ambulance Transport Services - Nonemergency MD-39
8.2.6 Anesthesia MD-40
8.2.6.1 Medical Direction by an Anesthesiologist MD-40
8.2.6.2 Anesthesia for Sterilization MD-41
8.2.6.3 Anesthesia for Labor and Delivery MD-41
8.2.6.4 Anesthesia Provided by the Surgeon (Other Than Labor and Delivery) MD-42
8.2.6.5 Complicated Anesthesia MD-42
8.2.6.6 Multiple Procedures MD-42
8.2.6.7 Monitored Anesthesia Care MD-42
8.2.6.8 Reimbursement Methodology MD-43
8.2.6.9 Anesthesia Modifiers MD-44
8.2.6.9.1 State-Defined Modifiers MD-44
8.2.6.9.2 Modifier Combinations MD-44
8.2.6.9.3 CRNA Services MD-45
8.2.6.10 Prior Authorization for Anesthesia MD-45
8.2.6.11 Claims Filing MD-46
8.2.6.12 Anesthesia (General) for THSteps Dental MD-46
8.2.7 Abdominal Aortic Aneurysm Screening MD-46
8.2.8 Bariatric Surgery MD-46
8.2.8.1 Prior Authorization for Bariatric Surgery MD-46
8.2.9 Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of Bladder Cancer MD-49
8.2.10 Behavioral Health Services MD-49
8.2.11 Biopsy MD-49
8.2.12 Blepharoplasty Procedures MD-49
8.2.13 BRCA Testing MD-50
8.2.13.1 Prior Authorization for Gene Mutation Analysis MD-51
8.2.13.2 Retroactive Authorization MD-52
8.2.13.3 Mammography (Screening and Diagnostic Studies of the Breast) MD-52
8.2.13.4 Prognostic Breast and Gynecological Cancer Studies MD-53
8.2.13.5 Colorectal Cancer Screening MD-54
8.2.13.6 Prior Authorization for Colorectal Cancer Screening MD-55
8.2.13.7 Genetic Testing for Colorectal Cancer MD-55
8.2.13.7.1 Testing for Familial Adenomatous Polyposis MD-56
8.2.13.7.2 Hereditary Nonpolyposis Colorectal Cancer (HNPCC) MD-56
8.2.13.7.3 Prior Authorization for Genetic Testing for Colorectal Cancer MD-57
8.2.14 Capsulotomy MD-57
8.2.15 Cardiac Rehabilitation MD-57
8.2.15.1 Prior Authorization for Cardiac Rehabilitation MD-59
8.2.15.2 Reimbursement MD-59
8.2.16 Casting, Splinting, and Strapping MD-60
8.2.17 Cardiopulmonary Resuscitation (CPR) MD-61
8.2.18 Chemotherapy MD-61
8.2.18.1 Chemotherapy Procedure Codes MD-62
8.2.19 Circumcisions MD-62
8.2.20 Closure of Wounds MD-63
8.2.21 Cochlear Implants MD-64
8.2.22 Continuous Glucose Monitoring (CGM) MD-64
8.2.22.1 Prior Authorization for Continuous Glucose Monitoring MD-64
8.2.23 Developmental and Neurological Assessment and Testing MD-64
8.2.23.1 Assessment of Aphasia MD-65
8.2.23.2 Developmental Screening MD-65
8.2.23.3 Developmental Testing MD-66
8.2.23.4 Neurobehavioral Testing MD-66
8.2.23.5 12-Hour Limitation for Procedure Codes 96110, 96111, and 96116 MD-69
8.2.24 Diagnostic Tests MD-69
8.2.24.1 Ambulatory Blood Pressure Monitoring MD-69
8.2.24.2 Ambulatory Electroencephalogram (Ambulatory EEG) MD-70
8.2.24.3 Bone Marrow Aspiration, Biopsy MD-70
8.2.24.4 Cytopathology Studies-Other Than Gynecological MD-70
8.2.24.5 Echoencephalography MD-71
8.2.24.6 Electrocardiogram (EKG) MD-72
8.2.24.7 Electrodiagnostic (EDX) Testing MD-74
8.2.24.7.1 Electromyography (EMG) MD-75
8.2.24.7.2 Nerve Conduction Studies (NCS) MD-75
8.2.24.7.3 Documentation Requirements for EDX Testing MD-76
8.2.24.7.4 Prior and Retrospective Authorization for EDX Testing MD-77
8.2.24.8 Esophageal pH Probe Monitoring MD-78
8.2.24.9 Helicobacter Pylori (H. Pylori) MD-78
8.2.24.10 Myocardial Perfusion Imaging MD-79
8.2.24.11 Pediatric Pneumogram MD-80
8.2.25 Diagnostic Doppler Sonography MD-80
8.2.26 Endoscopies MD-85
8.2.27 Extracorporeal Membrane Oxygenation (ECMO) MD-85
8.2.28 Family Planning MD-86
8.2.29 Gynecological Health Services MD-86
8.2.30 Hospital Visits MD-86
8.2.31 Hyperbaric Oxygen Therapy (HBOT) MD-86
8.2.32 Ilizarov Device and Procedure MD-88
8.2.33 Immunization Guidelines and Administration MD-88
8.2.33.1 Administration Fee MD-89
8.2.33.2 Documentation MD-89
8.2.33.3 Vaccine Adverse Event Reporting System (VAERS) MD-90
8.2.34 Immunizations for Clients Birth through 20 Years of Age MD-90
8.2.34.1 Vaccine Coverage Through the TVFC Program MD-91
8.2.34.2 Vaccine and Toxoid Procedure Codes MD-91
8.2.35 Immunizations for Clients Who Are 21 Years of Age and Older MD-94
8.2.36 Postexposure Prophylaxis for Rabies MD-96
8.2.36.1 Prior Authorization for Postexposure Rabies Vaccine MD-96
8.2.36.2 Limitations for Postexposure Rabies Vaccine MD-97
8.2.36.2.1 Obtaining Rabies Vaccine and HRIG from DSHS for PEP Use MD-97
8.2.37 Medications - Injectable MD-97
8.2.37.1 Abatacept (Orencia) MD-99
8.2.37.1.1 Prior Authorization for Abatacept (Orencia) MD-100
8.2.37.2 Alatrofloxacin Mesylate (Trovan) MD-100
8.2.37.3 Alglucosidase Alfa (Myozyme) MD-100
8.2.37.3.1 Prior Authorization for Alglucosidase Alfa (Myozyme) MD-100
8.2.37.4 17-Alpha Hydroxyprogesterone Caproate MD-101
8.2.37.5 Amifostine MD-101
8.2.37.6 Antibiotics and Steroids MD-102
8.2.37.7 Antihemophilic Factor MD-103
8.2.37.8 Botulinum Toxin Type A MD-103
8.2.37.9 Chelating Agents MD-104
8.2.37.9.2 Edetate calcium disodium MD-104
8.2.37.9.3 Deferoxamine mesylate (Desferal) MD-104
8.2.37.9.4 Edetate disodium MD-104
8.2.37.10 Clofarabine MD-105
8.2.37.10.1 Prior Authorization for Clofarabine MD-105
8.2.37.11 Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim) MD-105
8.2.37.12 Hematopoietic Injections MD-107
8.2.37.12.1 Epoetin Alfa (EPO) MD-108
8.2.37.12.2 Darbepoetin Alfa MD-108
8.2.37.13 Fluocinolone Acetonide (Retisert) MD-109
8.2.37.14 Gamma Globulin/Immune Globulin MD-109
8.2.37.15 Medroxyprogesterone Acetate (Depo Provera) MD-110
8.2.37.17 Iron Injections MD-112
8.2.37.18 Joint Injections and Trigger Point Injections MD-113
8.2.37.19 Leuprolide Acetate (Lupron Depot) MD-113
8.2.37.20.1 Prior Authorization for Omalizumab MD-113
8.2.37.22 Implantable Infusion Pumps MD-115
8.2.37.22.1 Prior Authorization for Implantable Infusion Pumps MD-115
8.2.37.22.2 Implantation of Catheters, Reservoirs, and Pumps MD-115
8.2.37.23 Trastuzumab MD-116
8.2.37.23.1 Prior Authorization for Trastuzumab MD-116
8.2.37.24 Injection Administration MD-116
8.2.37.25 Billing for Injectable Medications MD-117
8.2.37.26 Unit Calculations for Billing Drugs MD-117
8.2.38 Medications - Oral MD-118
8.2.39 Laboratory Services MD-118
8.2.39.1 THSteps Laboratory Services MD-118
8.2.39.2 Laboratory Handling Charge MD-118
8.2.39.3 Blood Counts MD-119
8.2.39.4 Clinical Lab Panel Implementation MD-119
8.2.39.5 Clinical Pathology Consultations MD-119
8.2.39.6 Cytogenetics Testing MD-120
8.2.39.7 Maternal Serum Alpha-Fetoprotein (MSAFP) MD-122
8.2.40 Lung Volume Reduction Surgery (LVRS) MD-122
8.2.40.1 Prior Authorization for Lung Volume Reduction Surgery MD-123
8.2.40.1.1 Noncovered Conditions MD-124
8.2.41 Mastectomy and Breast Reconstruction MD-125
8.2.41.1 Mastectomies MD-125
8.2.41.2 Prophylactic Mastectomies MD-126
8.2.41.3 Breast Reconstruction MD-126
8.2.41.4 Tattooing to Correct Color Defects of the Skin MD-128
8.2.41.5 Treatment for Complications of Breast Reconstruction MD-128
8.2.41.6 External Breast Prostheses MD-129
8.2.41.7 Prior Authorization Requirements for Mastectomy and
Breast Reconstruction MD-130
8.2.41.8 Limitations for Mastectomy and Breast Reconstruction MD-131
8.2.42 Neurostimulators MD-132
8.2.42.1 Prior Authorization for Neurostimulators MD-132
8.2.42.2 Neuromuscular Electrical Stimulation (NMES) MD-133
8.2.42.2.2 NMES Purchase MD-133
8.2.42.2.3 NMES for Muscle Atrophy MD-133
8.2.42.2.4 NMES for Walking in Clients with Spinal Cord Injury (SCI) MD-133
8.2.42.3 Transcutaneous Electrical Nerve Stimulation (TENS) MD-134
8.2.42.3.2 TENS Purchase MD-135
8.2.42.4 NMES and TENS Garments MD-135
8.2.42.5 NMES and TENS Supplies MD-135
8.2.42.6 Dorsal Column Neurostimulator (DCN) MD-136
8.2.42.6.1 Prior Authorization for Dorsal Column Neurostimulators MD-136
8.2.42.7 Intracranial Neurostimulators MD-136
8.2.42.7.1 Prior Authorization for Intracranial Neurostimulators MD-137
8.2.42.8 Percutaneous Electrical Nerve Stimulation (PENS) MD-137
8.2.42.8.1 Prior Authorization for PENS MD-137
8.2.42.9 Sacral Nerve Stimulators (SNS) MD-137
8.2.42.9.1 Prior Authorization for SNS MD-138
8.2.42.10 Vagal Nerve Stimulators (VNS) MD-138
8.2.42.10.1 Prior Authorization for VNS MD-138
8.2.42.11 Prior Authorization of Neurostimulator Devices Procedure Codes MD-138
8.2.42.12 Supplies for Neurostimulators MD-138
8.2.42.13 Electronic Analysis for Neurostimulators MD-139
8.2.42.14 Revision or Removal of Neurostimulator Devices MD-139
8.2.42.15 Noncovered Neurostimulator Services MD-139
8.2.43 Newborn Services MD-139
8.2.43.1 Circumcisions for Newborns MD-139
8.2.43.2 Claims Filing Instructions and Eligibility Requirements MD-140
8.2.43.3 Potential SSI/Medicaid Eligibility for Premature Infants MD-141
8.2.43.4 Hospital Visits and Routine Care MD-141
8.2.43.5 Newborn Hearing Screening MD-144
8.2.44 Obstetrics and Prenatal Care MD-145
8.2.44.1 Amniocentesis, Cordocentesis, and Ultrasonic Guidance MD-146
8.2.44.2 External Cephalic Version MD-146
8.2.44.3 Fetal Fibronectin MD-146
8.2.44.4 Fetal Intrauterine Transfusion (FIUT) MD-147
8.2.44.5 Doppler Studies MD-147
8.2.44.6 Fetal Echocardiography MD-147
8.2.44.7 Obstetric Ultrasound MD-148
8.2.44.8 Prenatal Surveillance MD-151
8.2.44.9 Documentation Requirements for Diagnostic Studies MD-152
8.2.44.10 Required Screening of Pregnant Women for Syphilis, HIV, and Hepatitis B MD-152
8.2.44.10.2 Hepatitis B and Syphilis Screening MD-152
8.2.45 Occupational Therapy (OT) Services MD-153
8.2.46 Ophthalmology MD-153
8.2.46.1 Corneal Transplants MD-153
8.2.46.2 Eye Surgery by Laser MD-153
8.2.46.2.1 Other Eye Surgery Procedures MD-153
8.2.46.3 Eye Surgery by Incision MD-155
8.2.46.4 Intraocular Lens (IOL) MD-156
8.2.46.5 Intravitreal Drug Delivery System MD-156
8.2.46.6 Other Eye Surgery Limitations MD-156
8.2.47 Organ/Tissue Transplants MD-156
8.2.47.1 Heart Transplants MD-157
8.2.47.1.1 Prior Authorization for Heart Transplants MD-157
8.2.47.1.2 Guidelines for Coverage of a Heart Transplant MD-157
8.2.47.2 Intestinal Transplants MD-157
8.2.47.2.1 Prior Authorization for Intestinal Transplants MD-157
8.2.47.2.2 Guidelines for Coverage of an Intestinal Transplant MD-157
8.2.47.2.3 Other Limitations for Intestinal Transplants MD-159
8.2.47.3 Kidney Transplants MD-159
8.2.47.3.1 Prior Authorization for Kidney Transplants MD-159
8.2.47.3.2 Guidelines for Coverage of a Kidney Transplant MD-159
8.2.47.3.3 Other Limitations for Kidney Transplants MD-159
8.2.47.4 Liver Transplants MD-160
8.2.47.4.1 Prior Authorization for Liver Transplants MD-160
8.2.47.4.2 Guidelines for Coverage MD-160
8.2.47.5 Lung Transplants MD-161
8.2.47.5.1 Prior Authorization for Lung Transplants MD-161
8.2.47.5.2 Guidelines for Coverage of a Lung Transplant MD-161
8.2.47.6 Pancreas Transplant and Simultaneous Kidney-Pancreas Transplant MD-162
8.2.47.6.1 Prior Authorization for Pancreas Transplant/Simultaneous
Kidney-Pancreas Transplant MD-162
8.2.47.6.2 Guidelines for Coverage of a Pancreas/Simultaneous
Kidney-Pancreas Transplant MD-162
8.2.47.6.3 Pancreas Transplant Alone MD-162
8.2.47.6.4 Simultaneous Kidney-Pancreas Transplant MD-163
8.2.47.7 Nonsolid Organ Transplants MD-163
8.2.47.7.1 Allogeneic and Autologous Bone Marrow and Stem
Cell Transplantation MD-164
8.2.47.7.2 Autologous Islet Cell Transplantation MD-165
8.2.47.7.3 Prior Authorization for Nonsolid Organ Transplants MD-165
8.2.47.8 Organ Procurement MD-166
8.2.47.9 Prior Authorization for All Transplants MD-166
8.2.48 Orthognathic Surgery MD-167
8.2.48.1 Prior Authorization for Orthognathic Surgery MD-167
8.2.49 Osteogenic Stimulation MD-168
8.2.50 Osteopathic Manipulative Treatment (OMT) MD-168
8.2.51 Pain Management MD-169
8.2.51.1 Epidural and Subarachnoid Infusion (Not Including Labor and Delivery) MD-170
8.2.52 Panniculectomy and Abdominoplasty MD-170
8.2.52.1 Panniculectomy MD-170
8.2.52.2 Abdominoplasty MD-172
8.2.53 Penile and Testicular Prostheses MD-173
8.2.54 Pentamidine Aerosol MD-173
8.2.55 Percutaneous Transluminal Coronary Interventions MD-174
8.2.56 Physical Therapy (PT) Services MD-174
8.2.57 Physician Evaluation and Management (E/M) Services MD-174
8.2.57.1 Office or Other Outpatient Hospital Services MD-175
8.2.57.1.1 New and Established Patient Services MD-175
8.2.57.1.2 Preventive Care Visits MD-176
8.2.57.1.3 Consultation Services MD-177
8.2.57.1.4 Services Outside of Business Hours MD-177
8.2.57.1.5 Observation Services MD-177
8.2.57.2 Domiciliary, Rest Home, or Custodial Care Services MD-178
8.2.57.3 Physician Services Provided in the Emergency Department MD-178
8.2.57.4 Group Clinical Visits MD-179
8.2.57.4.1 Group Clinical Visits for Diabetes MD-180
8.2.57.4.2 Group Clinical Visits for Asthma MD-180
8.2.57.5 Home Services MD-181
8.2.57.6 Inpatient Hospital Services MD-181
8.2.57.6.1 Hospital Admissions, Initial Visits, and Subsequent Visits MD-181
8.2.57.6.2 Concurrent Care MD-182
8.2.57.6.3 Consultations MD-182
8.2.57.6.4 Critical Care MD-183
8.2.57.6.5 Hospital Discharge MD-185
8.2.57.6.6 Nursing Facility Services MD-186
8.2.57.7 Prolonged Physician Services MD-187
8.2.57.8 Referrals MD-187
8.2.57.8.1 Referral Requirements for Children with Disabilities MD-187
8.2.58 Physician Services in a Long Term Care (LTC) Nursing Facility MD-188
8.2.59 Podiatry and Related Services MD-188
8.2.59.1 Clubfoot Casting MD-188
8.2.59.2 Flat Foot Treatment MD-188
8.2.59.3 Routine Foot Care MD-188
8.2.60 Prostate Surgery MD-188
8.2.61 Radiation Therapy MD-189
8.2.61.1 Brachytherapy MD-190
8.2.61.1.1 Prior Authorization for Brachytherapy MD-190
8.2.61.1.2 Other Limitations on Brachytherapy MD-190
8.2.61.2 Procedure Code Limitations MD-191
8.2.61.3 Stereotactic Radiosurgery MD-193
8.2.61.3.1 Prior Authorization for Stereotactic Radiosurgery MD-193
8.2.61.3.2 Other Limitations on Stereotactic Radiosurgery MD-194
8.2.62 Radiology Services MD-194
8.2.62.1 Diagnosis Requirements MD-195
8.2.62.2 Cardiac Blood Pool Imaging MD-196
8.2.62.3 Chest X-Rays MD-196
8.2.62.4 Magnetic Resonance Angiography (MRA) MD-198
8.2.62.5 Magnetic Resonance Imaging (MRI) MD-199
8.2.62.6 Technetium TC 99M MD-199
8.2.63 Reduction Mammaplasties MD-199
8.2.63.1 Prior Authorization for Reduction Mammaplasty MD-199
8.2.64 Renal Disease MD-200
8.2.64.1 Dialysis Patients MD-200
8.2.64.1.1 Physician Supervision of Dialysis Patients MD-200
8.2.64.2 Laboratory Services for Dialysis Patients MD-202
8.2.64.3 Self-Dialysis Patients MD-202
8.2.64.3.1 Physician Supervision MD-203
8.2.64.3.2 Initial Training MD-203
8.2.64.3.3 Subsequent Training MD-203
8.2.65 Respiratory Syncytial Virus (RSV) Prophylaxis MD-203
8.2.65.1 Benefits and Limitations MD-204
8.2.65.2 Prior Authorization Requirements MD-204
8.2.65.3 Obtaining Palivizumab MD-206
8.2.66 Sign Language Interpreting Services MD-208
8.2.67 Skin Therapy MD-208
8.2.68 Sleep Studies MD-211
8.2.68.1 Actigraphy MD-211
8.2.68.2 Pneumocardiograms MD-212
8.2.68.3 Polysomnography MD-212
8.2.68.4 Multiple Sleep Latency Test (MSLT) MD-213
8.2.68.5 Sleep Facility Restrictions for Polysomnography and Multiple
Sleep Latency Testing MD-214
8.2.69 Speech Therapy (ST) Services MD-215
8.2.70 Surgery Billing Guidelines MD-215
8.2.70.1 Primary Surgeon MD-215
8.2.70.2 Anesthesia Administered by Surgeon MD-215
8.2.70.3 Assistant Surgeon MD-216
8.2.70.4 Bilateral Procedures MD-216
8.2.70.5 Cosurgery MD-217
8.2.70.6 Global Fees MD-217
8.2.70.7 Multiple Surgeries MD-221
8.2.70.8 Office Procedures MD-221
8.2.70.9 Orthopedic Hardware MD-222
8.2.70.10 Second Opinions MD-222
8.2.70.11 Services Incidental to Surgery and/or Anesthesia MD-222
8.2.70.12 Supplies, Trays, and Drugs MD-224
8.2.71 Telemedicine Services MD-224
8.2.71.1 Distant Site MD-225
8.2.71.2 Patient Site MD-225
8.2.72 Therapeutic Apheresis MD-226
8.2.73 Therapeutic Phlebotomy MD-227
8.2.74 Therapeutic Radiopharmaceuticals MD-227
8.2.74.1 Prior Authorization for Therapeutic Radiopharmaceuticals MD-228
8.2.74.2 Other Limitations on Therapeutic Radiopharmaceuticals MD-228
8.2.75 Urethral Dilation MD-228
8.2.76 Ventilation Assist and Management for the Inpatient MD-229
8.2.77 Wearable Cardiac Defibrillator (WCD) MD-229
8.2.77.1 Prior Authorization for WCD MD-229
8.3 Doctor of Dentistry Practicing as a Limited Physician MD-232
8.3.1 Medicaid Managed Care Enrollment MD-232
8.3.2 Prior Authorization for General Dental Services Due to Life-Threatening
Medical Condition MD-232
8.3.2.1 Guidelines for Requesting Mandatory Prior Authorization MD-233
8.3.3 Benefits and Limitations MD-233
8.3.3.1 Diagnosis Codes MD-234
8.3.3.2 Evaluation and Management Procedure Codes MD-235
8.3.3.3 Additional Payable Procedure Codes MD-235
8.3.3.4 Immune Globulin by a Doctor of Dentistry as a Limited Physician MD-237
8.3.3.5 Radiographs by a Doctor of Dentistry Practicing as a Limited Physician MD-237
8.3.3.6 Dental Anesthesia by a Doctor of Dentistry Practicing
as a Limited Physician MD-237
8.4 Documentation Requirements MD-238
8.5 Claims Filing and Reimbursement MD-238
8.5.1 Claims Information MD-238
8.5.2 National Drug Codes (NDC) MD-238
8.5.3 Reimbursement MD-238
9. Physician Assistant MD-239
9.1 Enrollment MD-239
9.2 Services, Benefits, Limitations, and Prior Authorization MD-240
9.2.1 Prior Authorization MD-241
9.3 Documentation Requirements MD-241
9.4 Claims Filing and Reimbursement MD-241
9.4.1 Claims Information MD-241
9.4.2 Reimbursement MD-241
10. Claims Resources MD-242
11. Contact TMHP MD-243
12. Forms MD-243
MD.1 Abortion Certification Statements Form MD-244
MD.2 DME Certification and Receipt Form (3 pages) MD-245
MD.3 Hospital Report (Newborn Child or Children) (Form 7484) MD-248
MD.4 Hysterectomy Acknowledgment Form MD-249
MD.5 Medicaid Certificate of Medical Necessity for Reduction Mammaplasty MD-250
MD.6 Nonemergency Ambulance Prior Authorization Request Form (2 Pages) MD-251
MD.7 Obstetric Ultrasound Prior Authorization Request Instructions MD-253
MD.8 Obstetric Ultrasound Prior Authorization Request Form MD-254
MD.9 Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization Form MD-255
MD.10 Request for Extended Outpatient Psychotherapy/Counseling Form MD-256
MD.11 Special Medicaid Prior Authorization (SMPA) Request Form MD-257
MD.12 Sterilization Consent Form Instructions (2 pages) MD-258
MD.13 Sterilization Consent Form (English) MD-260
MD.14 Sterilization Consent Form (Spanish) MD-261
MD.15 Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Form MD-262
MD.16 Texas Medicaid Vendor Drug Program for Outpatient Pharmacies Synagis
(Palivizumab) Prior Authorization Request & Prescription Form for 2010 MD-263
MD.17 THSteps Dental Mandatory Prior Authorization Request Form MD-264
MD.18 THSteps Dental Criteria for Dental Therapy Under General Anesthesia (2 pages) MD-265
13. Claim Form Examples MD-267
MD.19 Anesthesia MD-268
MD.20 Certified Nurse-Midwife (CNM) MD-269
MD.21 Certified Registered Nurse Anesthetist (CRNA) MD-270
MD.22 Chiropractic Services MD-271
MD.23 Dental (Doctor of Dentistry) MD-272
MD.24 Dialysis Training MD-273
MD.25 Genetics MD-274
MD.26 Radiation Therapy MD-275
MD.27 Surgery Claim Form Example MD-276
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