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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.4 Durable Medical Equipment (DME) Supplier (CCP) : 2.4.7 Diabetic Equipment and Supplies : 2.4.7.2 Prior Authorization and Documentation Requirements

2.4.7.2
Prior authorization is required for the tubeless external insulin pump with carrying cases and related supplies and repairs. The tubeless external insulin pump supplies may be considered separately when a tubeless external insulin pump is rented.
The tubeless external insulin pump and supplies may be obtained through one of the following methods:
The completed CCP Prior Authorization Request Form must be maintained by the dispensing provider and the prescribing physician in the client's medical record. The physician must maintain the original signed and dated copy of the CCP Prior Authorization Request Form. The completed CCP Prior Authorization Request Form is valid for a period up to six months from the physician's signature date.
The verbal or detailed written order must be provided by a physician, physician assistant, nurse practitioner, clinical nurse specialist, or a certified nurse midwife.
If the dispensing provider does not have a detailed written order, a verbal order is required to be on file until the written order is received from the prescribing provider and before providing diabetic equipment and supplies. The prescribing provider's order may be a written, fax, electronic, or verbal order and must include:
A detailed written order must be received by the DME supplier within 90 days from the date of the prescribing provider's signature. For initial orders, the detailed written order for diabetic equipment and supplies is valid for six months from the date of the order or the date of the prescribing provider's signature, whichever is earlier. For renewal orders the detailed written order is valid for six months from the start date, or in absence of a start date, the date of the authorized prescribing signature.
2.4.7.2.1 Tubeless External Insulin Pump Rentals
Tubeless external insulin pump rentals may be considered for prior authorization with the submission of clinical documentation that indicates one of the following:
In addition to the clinical documentation, the provider must submit an External Insulin Pump form that indicates:
The client or caregiver will be given face-to-face education and instruction and will be able to demonstrate the necessary proficiency to integrate insulin pump therapy with their current treatment regimen for ambient glucose control.
The External Insulin Pump form has been updated to incorporate the required prior authorization criteria for the rental of the external insulin pump.
2.4.7.2.2 Purchase of Tubeless External Insulin Pump
The purchase of a tubeless external insulin pump may be considered for prior authorization after it has been rented for a three-month trial and all of the following documentation has been provided:

Texas Medicaid & Healthcare Partnership
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