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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 5: Fee-for-Service Prior Authorizations : 5.1 General Information About Prior Authorization

5.1 General Information About Prior Authorization
Some fee-for-service Medicaid services require prior authorization as a condition for reimbursement. Information about whether a service requires prior authorization, as well as prior authorization criteria, guidelines, and timelines for the service, is contained in the handbook within Volume 2 that contains the service.
Prior authorization is not a guarantee of payment. Even if a procedure has been prior authorized, reimbursement can be affected for a variety of reasons, e.g., the client is ineligible on the date of service (DOS) or the claim is incomplete. Providers must verify client eligibility status before providing services.
In most instances prior authorization must be approved before the service is provided. Prior Authorization for urgent and emergency services that are provided after business hours, on a weekend, or on a holiday may be requested on the next business day. TMHP considers providers’ business hours as Monday through Friday, from 8 a.m. to 5 p.m., Central Time. Prior authorization requests that do not meet these deadlines may be denied.
To avoid unnecessary denials, the request for prior authorization must contain correct and complete information, including documentation of medical necessity. The documentation of medical necessity must be maintained in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request for prior authorization.
Refer to:
Subsection 6.1.4, “Claims Filing Deadlines” in Section 6, “Claims Filing” (Vol. 1, General Information) for the TMHP-approved holidays.
Authorization requests for services administered by a client’s managed care organization (MCO) or dental plan must be submitted to the client’s MCO or dental plan according to the guidelines that are specific to the plan under which the client is covered.
Refer to:
Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks) for additional information about managed care prior authorizations.

Texas Medicaid & Healthcare Partnership
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