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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 : 9.2.62 Magnetoencephalography (MEG) : 9.2.62.1 Prior Authorization for MEG

9.2.62.1
Prior authorization is required for MEG. Prior authorization requests must be submitted using the Special Medical Prior Authorization (SMPA) Request Form. The ordering physician must sign and date the form and submit it to the SMPA department. Requests must include documentation supporting the medical necessity of the study. The ordering physician must maintain all documentation.
Providers must include information about the MEG test facility. This information must be documented on the SMPA form.
Prior authorization requests must include a completed SMPA request form and all of the following documentation:
The statement of medical necessity from the ordering physician, which must support the need for MEG with identified medical conditions as applicable, including:
Types of previous diagnostic testing used or considered and documentation that indicates how these tests have failed to provide the necessary information to address the client’s medical needs or when one or more conventional measures of localizing the seizure focus have failed to provide sufficient information
Documentation from the ordering physician outlining how the MEG test will assist in identifying the area to be resected in instances when an MEG test is needed due to a tumor and surgery is the first option.
Documentation that includes the name and number of medications, tried and failed, to control the client’s seizure activity when the MEG request is related to intractable epilepsy.
The date of prior MEG, the results of the previous MEG tests, and supporting medical documentation outlining the medical reasons for the repeat MEG requested if the request is for a repeat MEG.
Providers may submit prior authorization requests electronically, through the provider website, fax, or by standard mail.
The provider may complete and submit the required prior authorization documentation through any approved electronic method. The provider must maintain a copy of the prior authorization request as well as all submitted documentation in the client’s medical record at the performing provider’s place of business, in order to complete the prior authorization process electronically.
The provider may complete and submit the required prior authorization documentation through fax or standard mail and must maintain a copy of the prior authorization request as well as all submitted documentation in the client’s medical record at the performing provider’s place of business, to complete the prior authorization process by paper.
Providers must include correct and complete information, such as documentation of medical necessity for the service(s) requested, in order to avoid unnecessary denials. Providers 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.
Requests for prior authorization with documentation supporting the medical necessity for the number of studies requested must be received on, or before, the requested date(s) of service.
Note:

Texas Medicaid & Healthcare Partnership
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