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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 5: Fee-for-Service Prior Authorizations : 5.5 Prior Authorization Submission Methods : 5.5.1 Prior Authorization Requests Through the TMHP Website : Document Requirements and Retention
If information provided in the online request is insufficient to support medical necessity, TMHP Prior Authorization staff may ask the provider to submit additional paper documentation to support the medical necessity for the service being requested.
Submission of prior authorization requests on the secure pages of the TMHP website does not replace adherence to and completion of the paper forms/documentation requirements outlined in this manual and other publications.
Documentation requirements include, but are not limited to, the following:
Adherence to signature and date requirements for prior authorization forms and other required forms that are kept in the client record, including the following:
Any required documentation that is missing from the client's medical record subjects the associated payments for services to be recouped. Acknowledgement Statement
Before submitting each prior authorization request, providers (and submitters on behalf of providers) must affirm that they have read, understood, and agree to the certification and terms and conditions of the prior authorization request.
Providers and submitters are separately held accountable for their declarations after they have acknowledged their agreement and consent by checking the “We Agree” checkbox after reviewing the certification statement and terms and conditions. Certification Statement:
"The Provider and Authorization Request Submitter certify that the information supplied on the prior authorization form and any attachments or accompanying information constitute true, correct, and complete information. The Provider and Authorization Request Submitter understand that payment of claims related to this prior authorization will be from federal and state funds, and that falsifying entries, concealment of a material fact, or pertinent omissions may constitute fraud and may be prosecuted under applicable federal and/or state law. Fraud is a felony, which can result in fines or imprisonment.
"By checking ‘We Agree’ you agree and consent to the Certification above and to the TMHP `Terms and Conditions.'" Terms and Conditions:
"I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the state’s Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or U.S. Dept. of Health and Human Services may request. I further agree to accept, as payment in full, the amount paid by Medicaid for those claims submitted for payment under that program, with the exception of authorized deductible, coinsurance, copayment or similar cost-sharing charge. I certify that the services listed above are/were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction.
"Notice: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim, based on information provided on the Prior Authorization form, will be from federal and state funds, and that any false claims, statements or documents, or concealment of a material fact, may be prosecuted under applicable federal or state law."
Omission of information or failure to provide true and accurate information or notice of changes to the information previously provided may result in termination of the provider's Medicaid enrollment and/or personal exclusion from Texas Medicaid.

Texas Medicaid & Healthcare Partnership
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