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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 5: Fee-for-Service Prior Authorizations

Section 5: Fee-for-Service Prior Authorizations
5.1 General Information About Prior Authorization 5-2
5.1.1 Prior Authorization Requests for Clients with Retroactive Eligibility 5-2
5.1.2 Prior Authorization Requests for Newly Enrolled Providers 5-3
5.1.3 Prior Authorization for Services Rendered Out-of-State 5-3
5.1.4 Prior Authorization Requests for Clients with Private Insurance 5-3
5.1.5 Prior Authorization Requests for Clients with Medicare/Medicaid 5-3
5.1.6 Prior Authorizations for Personal Care Services (PCS) 5-4
5.1.6.1 Verifying the Texas Provider Identifier (TPI) on PCS Authorizations 5-4
5.1.7 Prior Authorization for Outpatient Self-Administered Prescription Drugs 5-5
5.2 Authorization Requirements for Unlisted Procedure Codes 5-5
5.3 Benefit Code 5-5
5.4 Submitting Prior Authorization Forms 5-6
5.5 Prior Authorization Submission Methods 5-6
5.5.1 Prior Authorization Requests Through the TMHP Website 5-7
5.5.1.1 Document Requirements and Retention 5-7
5.5.1.1.1 Acknowledgement Statement 5-8
5.5.1.1.2 Certification Statement: 5-8
5.5.1.1.3 Terms and Conditions: 5-8
5.5.2 Prior Authorization Requests to TMHP by Fax, Telephone, or Mail 5-9
5.5.2.1 TMHP Prior Authorization Requests by Fax 5-9
5.5.2.2 TMHP Prior Authorization Requests by Telephone 5-9
5.5.2.3 TMHP Prior Authorization Requests by Mail 5-10
5.5.3 Radiology Prior Authorizations Through MedSolutions 5-10
5.5.3.1 Online Prior Authorizations Through MedSolutions 5-10
5.5.3.2 Prior Authorizations to MedSolutions by Fax, Telephone, or Mail 5-10
5.5.3.3 Retroactive Authorization Requests 5-10
5.6 Verifying Prior Authorization Status 5-11
5.7 Prior Authorization Notifications 5-11
5.8 Prior Authorization Denials Appeals Process 5-11
5.9 Closing a Prior Authorization 5-12
5.10 Submitting Claims for Services That Require Prior Authorization 5-12
5.11 Guidelines for Procedures Awaiting Rate Hearing 5-12

Texas Medicaid & Healthcare Partnership
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