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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.6 Durable Medical Equipment (DME) Supplier (CCP) : 2.6.3 Prior Authorization and Documentation Requirements

2.6.3
Providers can request prior authorization for most DME through the TMHP website. Providers that make written requests for prior authorization must complete the CCP Prior Authorization Request Form on the TMHP website at www.tmhp.com, and they must attach the documentation necessary to support the request. The documentation must include a current prescription that has been signed and dated by a physician (M.D. or D.O.), and it must be mailed or faxed to TMHP with the prior authorization request. For specific policy information not contained in this manual related to the purchase of DME, providers can call TMHP-CCP Customer Service at 1‑800‑846‑7470.
A completed CCP Prior Authorization Request Form prescribing the DME or medical supplies must be signed and dated by the prescribing physician familiar with the client before requesting prior authorization. The completed CCP Prior Authorization Request Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept in the physician’s medical record for the client.
To complete the prior authorization process by paper, the DME provider must fax or mail the completed CCP Prior Authorization Request Form to the CCP prior authorization unit and retain a copy of the signed and dated CCP form in the client’s medical record at the provider’s place of business.
To complete the prior authorization process electronically, the DME provider must complete the prior authorization requirements through any approved electronic methods and retain a copy of the signed and dated CCP Prior Authorization Request form in the client’s medical record at the provider’s place of business.
To avoid unnecessary denials, the physician must provide correct and complete information, including accurate documentation of the medical necessity for the equipment and services requested. The physician 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 mobility aid.
A determination is made by the CCP nurses as to whether the equipment will be rented, purchased, repaired, or modified based on the client’s needs, duration of use, and age of equipment.
A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or expendable medical supply. Physician prescriptions must be specific to the item requested. For example, if the provider is requesting a customized wheelchair, the prescription must request a customized wheelchair, not just a wheelchair. Providers must submit a CCP Prior Authorization Request Form and documentation to support medical necessity to the CCP department before providing services. Providers must obtain prior authorization within three business days of the requested date of service.
Refer to:
Subsection 2.2.25, “Procedure Codes That Do Not Require Prior Authorization” in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks) for details about specific procedure codes that do not require prior authorization through Texas Medicaid (Title XIX) Home Health Services.

Texas Medicaid & Healthcare Partnership
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