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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) : 2.4.13 Phototherapy Devices : Prior Authorization and Documentation Requirements
Home phototherapy devices require prior authorization and are provided only for the days that are medically necessary.
For low-risk infants, prior authorization will be considered for phototherapy services that begin in the home.
For stabilized infants who began phototherapy treatment during their hospitalization and have been discharged from the hospital, prior authorization will be considered for the continuation of phototherapy services in the home. Initial prior authorization may be given for a maximum of seven days of home phototherapy. A new “CCP Prior Authorization Request Form” must be submitted to request more than seven days of home phototherapy.
The following documentation is required to support medical necessity when requesting home phototherapy services:
A diagnostic evaluation, which must include, but is not limited to, a normal history and physical exam, and normal laboratory values for the following, as medically indicated:
When requesting prior authorization for a hospitalized infant that requires continued home phototherapy, providers must submit documentation that indicates all pre-existing medium- or high-risk factors have resolved or stabilized.
Providers must submit the following additional documentation for prior authorization requests for previously hospitalized infants that require continued home phototherapy or for more than seven days of home phototherapy:
According to AAP guidelines, phototherapy may be discontinued when the TSB level falls below 13–14 mg/dl; however, exceptions to the guidelines may be considered. As a result, documentation must include the rationale for not discontinuing phototherapy when the TSB level drops below 13 mg/dl.
Note: Retroactive Eligibility
Newborn babies may not have a Medicaid number at the time that services are ordered by the physician and provided by the supplier. In these cases, prior authorization may be given retroactively for services rendered between the start date and the date that the client’s Medicaid number becomes available.
The provider has 95 days from the date on which the client’s Medicaid number becomes available (add date) to obtain prior authorization for services that were already rendered.

Texas Medicaid & Healthcare Partnership
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