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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 4 Noninvasive Prenatal Testing (NIPT) : 4.3 Prior Authorization

Prior authorization is required for NIPT procedure codes 81420 and 81507. The prior authorization request must be submitted on the Special Medical Prior Authorization (SMPA) Request Form completed, signed, and dated by the provider rendering direct care to the client, and include the performing laboratory’s TPI in section D of the form. The requesting provider must share the authorization number with the laboratory provider submitting the claim. Requests from laboratories will not be processed.
The expected dates of service requested in Section B of the Special Medical Prior Authorization (SMPA) Request Form must not exceed 45 days. Prior authorizations will only be approved for 45 days, during which time the client must obtain testing.
For prior authorization requests submitted before the client’s 10th week of gestation, the expected dates of service must begin no sooner than the 10th week of gestation. Approved prior authorizations will expire 45 days from the start of service date indicated on the SMPA form.
The provider must indicate on the prior authorization request form that the client meets required criteria (as noted above in Screening Criteria) for NIPT.
Prior authorization requests for sequencing analysis of fetal sex chromosome aneuploidy (procedure code 81420) must include a description of the medical need for the service on the prior authorization request form. Inadequate documentation for the addition of fetal sex chromosome aneuploidy screening may result in the denial of procedure code 81420. Providers may resubmit a request for procedure code 81420 without SCA screening, or may submit a request for procedure code 81507.
The request for prior authorization should document that the client was provided counseling regarding potential outcomes of aneuploidy screening, as well as potential outcomes of fetal sex chromosome aneuploidy screening when elected, and that she understands the implications associated with each possible aneuploidy result.
Prior authorization requests may be submitted to the TMHP Special Medical Prior Authorization Department via mail, fax, or the electronic portal. Providers may sign prior authorization forms and supporting documentation using electronic or wet signatures.
Medical documentation submitted by the provider must verify any indications the provider included on the form, such as the client’s age, history of affected pregnancy or family history, anomalous ultrasound findings, or abnormal maternal serum results. Requisition forms from the laboratory are not sufficient for verification of genetic history.
A no-call or inconclusive result is possible and further diagnostic testing is strongly recommended in these cases.
NIPT procedure codes 81420 and 81507 are limited to once per pregnancy. Additional tests will not be authorized.

Texas Medicaid & Healthcare Partnership
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