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December 2016 Texas Medicaid Provider Procedures Manual

Section 5: Fee‑for‑Service Prior Authorizations : 5.1 General Information About Prior Authorization : 5.1.1 Prior Authorization Requests for Clients with Retroactive Eligibility

5.1.1
Retroactive eligibility occurs when the effective date of a client’s Medicaid coverage is before the date 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.
When an authorization request is submitted for a client who has received retroactive Texas Medicaid eligibility, providers should notify TMHP to avoid potential delays. Providers can notify TMHP of the retroactive client eligibility in one of the following ways:
Add a comment in the additional comments field for authorization requests that are submitted online on the TMHP website at www.tmhp.com or on the eviCore website at
www.medsolutionsonline.com (for radiological imaging authorizations only).
Add a comment on the cover sheet or the authorization request form for authorizations that are faxed to TMHP or eviCore (for radiological imaging authorizations only).
If the authorization request is made by telephone, the caller can indicate to the representative at TMHP or eviCore (for radiological imaging authorizations only) that the client has retroactive Texas Medicaid eligibility.
For services provided to fee-for-service 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 3 business days of the date of service.
The provider is responsible for verifying eligibility. The provider is strongly encouraged to access the Automated Inquiry System (AIS) or TexMedConnect to verify eligibility frequently while providing services to the client. Client eligibility can also be verified through the Your Texas Benefits Medicaid card website at www.YourTexasBenefitsCard.com. 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.
Refer to:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.