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December 2016 Texas Medicaid Provider Procedures Manual

Section 5: Fee‑for‑Service Prior Authorizations

Section 5: Fee‑for‑Service Prior Authorizations
Table of Contents
5.1 General Information About Prior Authorization 4
5.1.1 Prior Authorization Requests for Clients with Retroactive Eligibility 4
5.1.2 Prior Authorization Requests for Newly Enrolled Providers 5
5.1.3 Prior Authorization for Services Rendered Out-of-State 5
5.1.4 Prior Authorization Requests for Clients with Private Insurance 6
5.1.5 Prior Authorization Requests for Clients with Medicare/Medicaid 6
5.1.6 Prior Authorizations for Personal Care Services (PCS) 6
5.1.6.1 Authorizations for Multiple PCS Clients Within the Same Household 7
5.1.6.2 Verifying the Texas Provider Identifier (TPI) on PCS Authorizations 7
5.1.7 Prior Authorization for Outpatient Self-Administered Prescription Drugs 7
5.1.8 Prior Authorization for Nonemergency Ambulance Transport 7
5.1.8.1 Appealing Non-Emergent Ambulance Claims Denied for Missing Prior Authorization Number 8
5.1.8.2 Prior Authorization Types, Definitions 9
5.1.8.3 Nonemergency Prior Authorization Process 9
5.1.8.4 Nonemergency Ambulance Exception Request 10
5.1.8.5 Documentation of Medical Necessity and Run Sheets 11
5.1.8.5.1 Documentation of Medical Necessity 11
5.1.8.5.2 Run Sheets 11
5.1.8.6 Nonemergency Prior Authorization and Retroactive Eligibility 12
5.1.9 Nonemergency Transport Authorization for Medicare and Medicaid Clients 12
5.2 Authorization Requirements for Unlisted Procedure Codes 13
5.3 Benefit Code 13
5.4 Submitting Prior Authorization Forms 14
5.4.1 Recreating TMHP Prior Authorization and Authorization Forms to Fill Out Electronically 15
5.5 Prior Authorization Submission Methods 15
5.5.1 Prior Authorization Requests Through the TMHP Website 15
5.5.1.1 Duplicate Validation Check 16
5.5.1.2 Document Requirements and Retention 16
5.5.1.2.1 Acknowledgement Statement 17
5.5.1.2.2 Certification Statement 17
5.5.1.2.3 Terms and Conditions 17
5.5.2 Prior Authorization Requests to TMHP by Fax, Telephone, or Mail 17
5.5.2.1 Prior Authorization Calls 18
5.5.2.2 TMHP Prior Authorization Requests by Fax 18
5.5.2.3 TMHP Prior Authorization Requests by Telephone 18
5.5.2.4 TMHP Prior Authorization Requests by Mail 19
5.5.3 Home Health Services Prior Authorizations 19
5.5.4 Radiology Prior Authorizations Through eviCore 19
5.5.4.1 Online Prior Authorizations Through eviCore 19
5.5.4.2 Prior Authorizations to eviCore by Fax, Telephone, or Mail 20
5.5.4.3 Retroactive Authorization Requests 20
5.6 Verifying Prior Authorization Status 20
5.7 Prior Authorization Notifications 20
5.8 Prior Authorization Denials Appeals Process 20
5.9 Closing a Prior Authorization 21
5.10 Submitting Claims for Services That Require Prior Authorization 21
5.10.1 Authorization and Manually Priced Claims 22
5.11 Guidelines for Procedures Awaiting Rate Hearing 22
 
 

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