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December 2016 Texas Medicaid Provider Procedures Manual

Telecommunication Services Handbook : 3 Services, Benefits, Limitations, and Prior Authorization : 3.4 Prior Authorization : 3.4.1 Prior Authorization of Telemonitoring Services

3.4.1
Procedure code 99090 with or without modifier GQ requires prior authorization. Home telemonitoring services may be approved for up to 60 days per prior authorization request. If additional home telemonitoring services are needed, the home health agency or hospital must request prior authorization before the current prior authorization period ends.
Requests for additional home telemonitoring services that are received after the current prior authorization expires will be denied for dates of service that occurred before the date the submitted request was received.
To be eligible for home telemonitoring services, clients who are diagnosed with diabetes or hypertension must exhibit two or more of the following risk factors:
A completed Home Telemonitoring Services Prior Authorization Request form must be submitted to request home telemonitoring services.
If the prior authorization form is not signed and dated by the physician, the form must be accompanied by a written order or prescription that is signed and dated by the physician, or a documented verbal order from the physician that includes the date that the verbal order was received. The verbal order may be documented on a plan of care or treatment plan.
Note:
A verbal order is considered current when the date received is on, or no more than, 30 days before the start of home telemonitoring services. A written order or prescription is considered current when it is signed and dated on, or no more than, 30 days before the start of home telemonitoring services.
A request received without a physician’s signature, documented verbal order, or written prescription will not be processed and will be returned to the provider.
The request must include the physician-ordered frequency of the clinical data transmission and the client’s diagnoses and risk factors that qualify the client for home telemonitoring services.
Providers can also request prior authorization online through the secure TMHP provider portal. The initial request for prior authorization must be received no more than three business days from the date that the home telemonitoring services are initiated. Requests that are received after the three business-day period will be denied for dates of service that occurred before the date that the request was received.

Texas Medicaid & Healthcare Partnership
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