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December 2016 Texas Medicaid Provider Procedures Manual

Vision and HearingServices Handbook : 4 Vision Care Professionals : 4.3 Services, Benefits, Limitations, and Prior Authorization : 4.3.9 Prior Authorization

4.3.9
Prior authorization is required for the following:
A completed Special Medical Prior Authorization (SMPA) Request Form must be submitted by fax or mail to the Special Medical Prior Authorization department. The form must be signed and dated by a physician familiar with the client before requesting prior authorization. The completed Special Medical Prior Authorization (SMPA) Request Form must include the procedure codes and numerical quantities for services requested. The completed, signed, and dated Special Medical Prior Authorization (SMPA) Request Form must be maintained by the provider and the prescribing physician in the client’s medical record.
To avoid unnecessary denials, the physician must provide correct and complete information, including documentation for medical necessity of the vision service requested. The physician 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 for the vision service.

Texas Medicaid & Healthcare Partnership
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