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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.8 Personal Care Services (PCS) (CCP) : 2.8.3 Prior Authorization and Documentation Requirements

2.8.3
Prior authorization is required before services are provided. All PCS must be prior authorized by a DSHS case manager based upon client need, as determined by the client assessment. DSHS prior authorizes PCS for eligible clients. The DSHS case manager notifies TMHP of the authorized quantity of PCS. TMHP sends a notification letter with the PAN to the client or responsible adult and the selected PCS provider if PCS is approved or modified. Only the client or responsible adult receives a notification letter with an explanation of denied services. PCS is prior authorized for 12-month periods. PCS providers must provide services from the start of care date agreed to by the client or responsible adult, the case manager, and the PCS provider.
A PCS provider may obtain prior authorization to provide enhanced PCS to clients with a behavioral health condition when the following criteria are met:
The PCAF indicates that the identified behavioral health condition impacts the client’s ability to perform an activity of daily living (ADL) or an instrumental activity of daily living (IADL).
When a client experiences a change in condition, the client or responsible adult must notify the DSHS Health Service Office in the client’s region. A DSHS case manager must perform a new assessment and prior authorize any revisions in the quantity of PCS based on the new assessment. TMHP issues a revised authorization and notifications are sent to the client or responsible adult and the selected PCS provider. If the change is made during a current 12-month prior authorization period, the new prior authorization will maintain the same end date as the original 12-month prior authorization period. The revised authorization period will begin on the SOC date stated in the new assessment.
For continuing and ongoing PCS needs beyond the initial 12-month prior authorization period, a DSHS case manager must conduct a new assessment and submit a new authorization request to TMHP. TMHP sends a notification letter updating the prior authorization to the client, responsible adults, and the selected PCS provider.
Providers can call a toll-free PCS Provider Inquiry Line at 1‑888‑648‑1517 for assistance with inquiries about the status of a PCS prior authorization. Providers should direct inquiries about other Medicaid services to the TMHP Contact Center at 1‑800‑925‑9126. PCS providers should encourage the client or responsible adult to contact the appropriate DSHS Health Service Region with inquiries or concerns about the PCS assessment.

Texas Medicaid & Healthcare Partnership
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