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8.3.2.2 Nonemergency Prior Authorization Process
Medicaid providers and TMHP use the following prior authorization process:
1) |
The client's physician, nursing facility, Intermediate Care Facility for the Mentally Retarded (ICF-MR), health-care provider, or other responsible party completes the online prior authorization request on the TMHP website at www.tmhp.com. Alternately, the provider may fax a copy of the "Ambulance Fax Cover Sheet" to the TMHP Ambulance Unit at 1-512-514-4205. A request may be submitted up to 60 days before the date on which the non-emergency transport will occur. Information and documentation listed on the form must be sent with the request before the transport to the medical appointment. Documentation requirements are outlined in this section under "Supporting Documentation" . |
2) |
TMHP reviews all of the documentation it receives. An online prior authorization request submitted on the TMHP website at www.tmhp.com is responded to with an online approval or denial. Alternately, a letter of approval or denial is faxed to the requesting provider. The client is notified by mail if the authorization request is denied or downgraded. Reasons for denial include documentation that does not meet the criteria of a medical condition that is appropriate for transport by ambulance, or that the client is not eligible for the dates of services requested. Clients may appeal prior authorization request denials by contacting TMHP Client Notification at 1-800-414-3406. |
3) |
The requesting provider contacts the transporting ambulance provider and supplies the ambulance provider with the PAN and the dates of service that were approved. |
4) |
Hospitals may call TMHP at 1-800-540-0694, complete the online authorization request, or fax to 1-512-514-4205 to request a PAN when discharging a client or transporting the client to another facility. |
Refer to: "Prior Authorization Requests Through the TMHP Website" for additional information, including mandatory documentation requirements and retention.
Providers are not required to fax medical documentation to TMHP; however, in certain circumstances, TMHP may request the hospital fax the supporting documentation.
Incomplete online or faxed request forms are not considered a valid authorization request and are returned as a denial.
Ambulance provider claims submitted without a PAN are denied. A provider who is denied payment for nonemergency ambulance transport because of failure to obtain prior authorization or because a request for prior authorization was denied can appeal to TMHP. If the review shows that prior authorization was not obtained before transport, the denial of reimbursement will be upheld. If the review shows that prior authorization was obtained before transport or that the request for prior authorization was improperly denied based on the documentation of medical necessity submitted initially, the denial of reimbursement may be overturned.
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