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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.9 Private Duty Nursing (CCP) : 2.9.3 Prior Authorization and Documentation Requirements : 2.9.3.1 Retroactive Client Eligibility

2.9.3.1
Retroactive eligibility occurs when the effective date of a client’s Medicaid coverage is before the date that the client’s Medicaid eligibility is added to TMHP’s eligibility file, which is called the “add date.”
For clients with retroactive eligibility, prior authorization requests must be submitted after the client’s add date and before a claim is submitted to TMHP.
For services provided to Medicaid clients during the client’s retroactive eligibility period (i.e., the period from the effective date to the add date, prior authorization must be obtained within 95 days from the client's add date and before a claim for those services is submitted to TMHP). For services provided on or after the client’s add date, the provider must obtain prior authorization within three business days of the date of service.
The provider is responsible for verifying eligibility. The provider is strongly encouraged to access AIS or TexMedConnect to verify eligibility frequently while providing services to the client. If services are discontinued before the client’s add date, the provider must still obtain prior authorization within 95 days of the add date to be able to submit claims.

Texas Medicaid & Healthcare Partnership
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