TMPPM 2008 > Texas Medicaid Services > Texas Medicaid (Title XIX) Home Health Services > Reimbursement

24.3.2 Prior Authorization

Prior authorization of initial coverage of home health services (SN, HHA, PT, OT) for an eligible client can be obtained by calling the TMHP Contact Center Home Health Services line at 1-800-925-8957, by fax to 1-512-514-4209 or through the TMHP website at www.tmhp.com.

The following authorization requests can be submitted through the TMHP website at www.tmhp.com:

•Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form.

•Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy.

•Medicaid Certificate of Necessity for Chest Physiotherapy Device Form-Initial Request.

•Medicaid Certificate of Necessity for Chest Physiotherapy Device Form-Extended Request.

•Statement for Initial Wound Therapy System In-Home Use.

•Statement for Recertification of Wound Therapy System In-Home Use.

•Wheelchair/Scooter/Stroller Seating Assessment Form (THSteps-CCP/Home Health Services) (Attachments will be sent separately due to size and detailed information).

•Home Health Services Plan of Care (POC).

Refer to: "Prior Authorization Requests Through the TMHP Website" for more information, including mandatory documentation requirements.

If a client's primary coverage is private insurance, and Medicaid is secondary, prior authorization is required for Medicaid reimbursement.

If the primary coverage is Medicare, and Medicare approves the service, and Medicaid is secondary, prior authorization is not required. TMHP will only pay the coinsurance.

If Medicare denied the service, then Medicaid prior authorization is required. Contact Medicaid within 30 days of receipt of Medicare's final denial letter. The final denial letter from Medicare must accompany the authorization request.

If the service is a Medicaid-only service, prior authorization is required.

The provider is responsible for determining if eligibility is effective by using AIS or an electronic eligibility inquiry through TMHP EDI gateway.

The provider must contact TMHP Home Health Services Authorization Department within three business days of the start of care (SOC) for professional services or the DOS for DME/medical supplies to obtain authorization. Following the registered nurse's (RN) assessment/evaluation of the client in the home setting, the nurse who made the initial assessment visit in the client's home should make this call to answer questions about the client's condition as it relates to the medical necessity.

If inadequate or incomplete information is provided or is lacking medical necessity, the provider will be requested to furnish additional documentation as required to make a decision on the request. Providers have two weeks to submit the requested documentation because it often must be obtained from the client's physician. If the additional documentation is received within the two-week period, authorization can be considered for the original date of contact. If the additional documentation is received more than two weeks from the request for the documentation, authorization is not considered before the date the additional documentation is received. It is the DME/supplier/home health agency's responsibility to contact the physician to obtain the requested additional documentation.

TMHP's Home Health Services toll-free number is 1-800-925-8957. The Home Health Services Authorization Checklist is a useful resource for home health agency providers completing the authorization process. This optional form offers the nurse a detailed account of the client's needs when completed. Contact TMHP In-Home Care Contact Center at 1-800-846-7470 for more information.

Refer to: "Durable Medical Equipment (DME) and Supplies" for DME/medical supplies prior authorization and "Medicaid Relationship to Medicare" .

Client eligibility for Medicaid is for one month at a time. Providers should verify eligibility every month. Prior authorization does not guarantee payment.