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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) : 2.4.16 Vitamin and Mineral Products : Prior Authorization and Documentation Requirements
Prior authorization for vitamin and mineral products must be requested using the CCP Prior Authorization Request Form. Requests for prior authorizations must be submitted and approved before the date of dispensing the vitamin or mineral products. Prior authorization requests for vitamin and mineral products that are initiated before the date of the physician’s order will not be approved.
The following documentation must be submitted with the prior authorization request:
The following sample tables, taken from the CCP Prior Authorization Request Form, are examples of the information that is required to submit a request for vitamin and mineral products:
Note: HCPCS codes and descriptions must be provided.
Note: HCPCS codes and descriptions must be provided.
Prior authorization requests for products, conditions, or quantities other than those described in the “Benefits” section of this article will be considered on a case-by-case basis after review by the medical director. Providers must submit documentation that the prescribed products are for a medically accepted indication. Documentation must include one of the following:
Two articles from major medical peer-reviewed literature that demonstrate validated, uncontested data for the use of the agent in a specific medical condition that is safe and effective
Prior authorization of vitamin and mineral products may be granted for up to six months, and for a quantity up to a 30-day supply. Requests for additional vitamin and mineral products must be submitted before the current authorized period expires, but no more than 30 days before the expiration.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.