TMPPM 2010 > Volume 1, General Information > Section 5: Prior Authorization > Guidelines for Procedures Awaiting Rate Hearing


5.9 Guidelines for Procedures Awaiting Rate Hearing

For procedure codes that require prior authorization but are awaiting a rate hearing, providers must follow the established prior authorization processes as defined in the applicable provider handbook. Providers must obtain a timely prior authorization for services provided. Providers must not wait until the procedure codes have completed the rate hearing process to request prior authorization. Retroactive prior authorization requests are not granted; the requests are denied as late submissions. Providers are also responsible for meeting the initial 95-day filing deadline and for ensuring that the prior authorization number appears on the claim the first time it is submitted to TMHP for consideration of reimbursement.

The affected procedure codes are denied as pending a rate hearing. No further action on the part of the provider is necessary. Once the rates are established, TMHP automatically reprocesses the claims. If the required prior authorization number is not on the claim at the time of reprocessing, the claim is denied for lack of prior authorization.

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