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December 2016 Texas Medicaid Provider Procedures Manual

Certified Respiratory Care Practitioner (CRCP) Services Handbook : 3 CRCP Services : 3.1 Services, Benefits, Limitations, and Prior Authorization : 3.1.1 Authorization Requirements

Prior authorization requests may be submitted to the TMHP Prior Authorization Department via mail, fax, or the electronic portal. Prescribing or ordering providers, dispensing providers, clients’ responsible adults, and clients may sign prior authorization forms and supporting documentation using electronic or wet signatures.
Refer to:
Subsection, “Document Requirements and Retention” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for additional information about electronic signatures.
Prior authorization is required for in-home certified respiratory care practitioner services (procedure code 99504).
To avoid unnecessary denials, the provider must submit correct and complete information including documentation of medical necessity for the service requested. The prescribing physician and provider must maintain documentation of medical necessity in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request for the service.
Prior authorization requests for traditional Medicaid clients must be submitted by the physician or the certified respiratory care practitioner to the Special Medical Prior Authorization (SMPA) Department by approved electronic method using the “Special Medical Prior Authorization (SMPA) Request Form.”
Refer to:
When required, the requests must include the physician’s signature and the date signed. Without this information, requests will be considered incomplete.
The SMPA Request Form must be submitted with the following documentation supporting medical necessity for the requested procedure:
Documentation supporting why the respiratory therapy visits included in the Home Health DME rental of a ventilator, or the monthly respiratory therapy visit included in the Ventilator Service Agreement authorized to a Home Health DME provider would not meet the client’s medical needs.
The request may be authorized for up to a 12-month period. Requests for more than 24 visits in a 12-month period will be referred for the medical director to review and a determination will be based on the individual client’s medical needs.
Retrospective review may be performed to ensure documentation supports the medical necessity of the service when billing the claim for the procedure codes listed within the policy.

Texas Medicaid & Healthcare Partnership
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