43.4.1.6 Prior Authorization and Documentation RequirementsPrior 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 THSteps-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 "Prior Authorization Requests Through the TMHP Website" 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 provider of service (such as the DME supplier, pharmacy, RN, or physical therapist [PT]) receives a letter that includes the PAN, the procedures authorized, and the length of the authorization. Providers are notified in writing whether additional information is needed to process the request for services. Written requests for prior authorization are mandatory for the following services:
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• Submit a THSteps-CCP Prior Authorization Request Form and documentation to support medical necessity to the THSteps-CCP department before providing services. Important: Documentation to support medical necessity of the service, equipment, or supply (such as prescription, letter, and therapy notes) must be current, signed, and dated by a physician (MD or DO) before services are performed. Providers must keep the information on file. Refer to: THSteps-CCP provider-specific sections for prior authorization requirements of specific services. Diagnosis Coding All providers should obtain the client's medical diagnosis from the physician. This information must be reflected on each claim submitted to TMHP using ICD-9-CM coding. Purchase Versus Equipment Rental When providing equipment not authorized under Texas Medicaid (Title XIX) Home Health Services for THSteps-CCP clients with long-term or chronic conditions, it is more cost-effective, in many cases, to purchase the equipment rather than rent it. The client's condition and length of time the equipment will be used should be carefully assessed before authorization for rental or purchase is requested. THSteps-CCP does not pay for the purchase of certain types of equipment (e.g., apnea monitors); consequently, long-term rental may be considered. Most other equipment is rented for only four months initially. During this time, the provider should assess whether the equipment should be purchased before the rental lapses. Rentals must be prior authorized. After prior authorization is obtained for purchase, the new equipment must be provided and rental discontinued. THSteps-CCP does not purchase used equipment. Note: Prior authorization is a condition for reimbursement, not a guarantee of payment. Providers of customized or nonbasic medical equipment also must be enrolled as Medicare DME providers. Drug Approval, Medical Device Manufacturers may request drug or medical device products be added to THSteps-CCP by sending the information in writing to the following address:
HHSC HHSC reviews the information. Requests for consideration should not be sent to TMHP. Refer to: "THSteps-CCP ECI Request for Initial/Renewal Outpatient Therapy". |
Apnea monitors for clients older than 4 months of age or after an initial two months of rental.
