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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.14 Blood Factor Products

9.2.39.14
The following blood factor products procedure codes are a benefit of Texas Medicaid:
 
Procedure code J7199 requires prior authorization and must be submitted to the Special Medical Prior Authorization (SMPA) Procedure code J7199 is the only blood factor product that requires prior authorization. Supporting documentation that must be submitted with electronic or paper requests for prior authorization must include the following:
Reimbursement is available when the antihemophilic product is administered by or under personal physician supervision. All documentation must include the authorization request form and be maintained in the client’s medical record and is subject to retrospective review.

Texas Medicaid & Healthcare Partnership
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