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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 5 Ambulatory Surgical Center and Hospital Ambulatory Surgical Center : 5.2 Services, Benefits, Limitations, and Prior Authorization : 5.2.9 Implantable Infusion Pumps : Prior Authorization for Implantable Infusion Pump
Implantable infusion pumps (procedure codes E0782, E0783, and E0786) require prior authorization.
Prior authorization is not required for the physician services associated with the insertion, revision, removal, refilling, or maintenance of the IIP.
Providers must request prior authorization for the implantable infusion pump through the SMPA department with the supporting documentation for medical necessity. Send authorization requests to:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: 1-512-514-4213
Requests for prior authorization can be submitted online through the TMHP website at
Refer to:
Subsection, “Prior Authorization for Implantable Infusion Pumps,” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2 Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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