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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) : 2.6.8 Donor Human Milk : 2.6.8.2 Prior Authorization and Documentation Requirements

2.6.8.2
Donor human milk may be considered for a maximum of six months per authorization. The authorization may be extended with documentation of medical necessity.
Prior authorization is required for donor human milk provided through Texas Medicaid CCP Services. To obtain prior authorization, providers must complete the CCP Prior Authorization Request Form and a Donor Human Milk Request Form every 180 days. Both the ordering physician and the providing milk bank must maintain copies of the form in the client’s medical records.
The physician ordering the donor human milk must complete all of the fields in Part A of the original form, including the documentation of medical necessity. This information must be substantiated by written documentation in the clinical report. The physician must specify the quantity and the time frame in the Quantity Requested field (e.g., cubic centimeters per day or ounces per month). All of the fields in Part B of the form must be completed by the donor milk bank providing the donor human milk.
The prior authorization request and all completed documentation must be submitted to the TMHP CCP Prior Authorization Unit at:
Texas Medicaid & Healthcare Partnership
Comprehensive Care Program (CCP)
PO Box 200735
Austin, TX 78720-0735
Fax: 1-512-514-4212
The documentation of medical necessity and appropriateness and the signed and dated written informed consent form must be maintained in the client’s clinical records. The documentation of medical necessity must be completed by the physician ordering the donor human milk. The clinical records are subject to retrospective review. The documentation must address all of the following:
Medical necessity, including why the particular client cannot survive and gain weight on any appropriate formula (e.g., elemental, special, or routine formula or food), or any enteral nutritional product other than donor human milk.
Refer to:
CCP Prior Authorization Request Form on the TMHP website at www.tmhp.com.

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