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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.1 CCP Overview : 2.1.4 Prior Authorization and Documentation Requirements : 2.1.4.1 Incomplete Prior Authorization Requests

2.1.4.1
Providers must respond to an incomplete prior authorization request within 14 business days of the request receipt date. Incomplete prior authorization requests are requests that are received by TMHP with missing, incomplete, or illegible information.
Prior to denying an incomplete request, TMHP’s Prior Authorization department will attempt to get the the correct information from the requesting provider. The Prior Authorization department will make a minimum of three attempts to contact the requesting provider before sending a letter to the client about the status of the request and the need for additional information.
If the necessary information to make a prior authorization determination is not received within 14 business days of the request receipt date, the request will be denied as “incomplete.” To ensure timely processing, providers should respond to requests for missing or incomplete information as quickly as possible.
For fee-for-service (FFS) Medicaid requests that require a physician review before a final determination can be made, TMHP’s Physician Reviewer will complete the review within three business days of receipt of the completed prior authorization request. An additional three business days will be allowed for requests that require a peer-to-peer review with the client’s prescribing physician.

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