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December 2016 Texas Medicaid Provider Procedures Manual

Certified Respiratory Care Practitioner (CRCP) Services Handbook : 4 CRCP-CCP Services : 4.1 Services, Benefits, Limitations, and Prior Authorization : 4.1.1 Authorization Requirements

4.1.1
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 5.5.1.2, “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’s services.
To avoid unnecessary denials, the provider must submit correct and complete information, including documentation for medical necessity of the service requested. The provider ordering the service and the provider performing the service 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.
A completed CRCP Prior Authorization Request Form requesting these services must be signed and dated by the treating physician familiar with the client before requesting prior authorization. A copy of the completed, signed, and dated CRCP Prior Authorization Request Form must be maintained by the provider in the client’s medical record. The completed CRCP Prior Authorization Request Form with the original dated signature must be maintained by the physician in the client’s medical record.
To complete the prior authorization process electronically, the provider must complete the prior authorization requirements through any approved electronic methods and retain a copy of the signed and dated CRCP Prior Authorization Request Form in the client’s medical record at the provider’s place of business.
To complete the prior authorization process by paper, the provider must fax or mail the completed CRCP Prior Authorization Request Form to the CCP Prior Authorization Unit and retain a copy of the signed and dated CRCP Prior Authorization Request Form in the client’s medical record at the provider’s place of business.
The following documentation must be submitted to the CCP Prior Authorization Unit for prior authorization:
Client’s primary diagnosis with details of current suboptimal respiratory status and history of more than one emergency room or acute care clinic visits within the last three months
Reason this service or education needs to be provided in the home setting and cannot be provided in the office or facility setting. These may include, but are not limited to:
Prior authorization is required for procedure code S9441, and services must be performed by a certified respiratory care practitioner who has been certified by the National Asthma Educator Certification Board (NAECB) as a certified asthma educator. Certification documentation must be provided with the CRCP Prior Authorization Request Form in order to be considered for prior authorization.
Asthma conditions may include, but are not limited to:
Prior authorization is required for procedure codes 98960 and 99503. Respiratory conditions may include, but are not limited to:
Prior authorization will not be considered for certified respiratory care practitioners to perform routine respiratory treatment or services in the home.
Prior authorization requests for conditions or quantities beyond those limits established in this policy (two per lifetime) will be considered on a case-by-case basis upon review by the Texas Medicaid & Healthcare Partnership (TMHP) Medical Director. The following additional information must be provided:
Documentation of how the objectives of prior visits have not been achieved to support the need for additional visits beyond those limits established in this policy.

Texas Medicaid & Healthcare Partnership
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