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Changes to the Sterilization Consent Form and Instructions, Approval Process, and Denial Letter

Last updated on 7/15/2016

Note: This article applies to transactions submitted to TMHP for processing. For transactions processed by a Medicaid managed care organization (MCO), providers must refer to the MCO for information about benefits, limitations, prior authorization, and reimbursement.

Effective September 1, 2016, the following changes will be made to the Sterilization Consent Form and corresponding instructions, the Sterilization Consent Form Denial Letter, and the process that providers must follow to submit the consent form to TMHP. The changes include the following:

  • The Sterilization Consent Form and instructions have been updated to include field numbers and asterisks to indicate required fields.
  • The first submission of the Sterilization Consent Form received by TMHP will be processed, and resubmissions of the form with corrections will not be processed.
  • If deficiencies are found with the submitted Sterilization Consent Form, necessary corrections (if applicable) can be resubmitted to TMHP using the space provided on the Sterilization Consent Form Denial Letter that will be faxed to providers if deficiencies are found.
  • Certain corrections to the Sterilization Consent Form will no longer be allowed, and the form will not be approved.
  • For certain corrections, providers may be allowed three attempts to make the necessary corrections using the Denial Letter. If all requirements are not met upon the third attempt, the Sterilization Consent Form will not be approved.

These changes will impact Texas Medicaid Title XIX family planning services, the Healthy Texas Women’s (HTW) program, the Department of State Health Services (DSHS) Family Planning Program (DFPP), and Expanded Primary Health Care (EPHC) providers.

Important: Beginning September 1, 2016, consent forms that have not yet been approved will begin to be processed according to these new requirements. Even if a consent form has been submitted multiple times on or before August 31, 2016, the first version of the form that is submitted on or after September 1, 2016, will be considered the official submission, and the provider will be afforded three attempts to correct any deficiencies.

Required Fields

The Sterilization Consent Form has been updated to identify required fields with an asterisk (*). Fields indicated with a double asterisk (**) are required only under certain conditions. Each field has been numbered for easier identification.

All Sterilization Consent Forms will be considered based fields required for processing and fields required for approval.

Fields Required for Processing

The following fields will be required in order to process the consent form and notify the provider if deficiencies are found and corrections are necessary:

  • 29. TPI: If this field is missing or invalid, the consent form cannot be processed. This field must be corrected on the Denial Letter.
  • 30. NPI: If this field is missing or invalid, the consent form cannot be processed. This field must be corrected on the Denial Letter.
  • 33. Provider/Clinic Fax Number: If this field is missing or invalid, the provider will not receive notice if the consent form is denied or requires additional information.

Important: Providers must use the space indicated in the Denial Letter to submit corrections to TMHP. Providers must not resubmit a corrected Sterilization Consent Form. Only the first submission of the form received by TMHP will be processed; resubmissions of the Sterilization Consent Form will not be considered.

Fields Required for Approval: Corrections Permitted

Certain fields on the consent form are required for the submitted form to be approved. If information in the required fields is missing, invalid, or illegible, TMHP will fax the provider a Sterilization Consent Form Denial Letter requesting the corrected information and documentation indicating the correct information if applicable. Acceptable documentation includes a copy of the applicable pages of the operative report, a copy of the client’s valid Texas-issued ID or driver’s license, or a copy of the applicable pages of the client’s medical record, as appropriate.

Note: The entire operative report or client medical record is not required. A copy of the applicable pages of the operative report or client’s medical record is acceptable.

The “Reference #” indicated at the top of each page of the Sterilization Consent Form Denial Letter must be included on each page of the submitted documentation to avoid delays in processing.

The following fields are required in order for the consent form to be approved, and unless otherwise indicated with an asterisk (*), acceptable documentation must be submitted with proof of the correct information:

Consent to Sterilization

  • 5. Client's birthday [month, day, year]
  • 6. Client’s full name

The client’s state-issued license is sufficient to document the client’s name if necessary.

Interpreter’s Statement

  • 14 Interpreter’s Signature
  • 15 Date of Signature

The Interpreter’s Statement must only be completed if a third party’s services were required to ensure the client understands the procedure in the client’s primary language (other than English).

If the Interpreter’s Statement section is completed in error, providers will be required to provide documentation that an interpreter’s services were used. If an interpreter’s services were required and the Interpreter’s Signature and Date of Signature are left blank, the consent form will receive a final denial.

Note: If the date in field 15 is completed but does not meet requirements, providers will be given the opportunity to submit documentation to correct the date if errors need to be corrected. If this date of signature is missing, the consent form will receive a final denial and cannot be resubmitted to TMHP.

Statement of Person Obtaining Consent

  • 16. Client’s full name
  • 17. Specify type of operation
  • 19. Date of Signature
  • 20. Facility Name: (*documentation not required)
  • 21. Facility Address: (*documentation not required)

Physician’s Statement

  • 22. Name of individual to be sterilized
  • 23. Date of sterilization
  • 24. Specify type of operation
  • 25. Choose one of the two statements as applicable
  • 26a. Expected date of delivery (mm/dd/yyyy)
  • 26b. Emergency abdominal surgery; describe circumstances (operative report required)
  • 28. Date of Signature

Note: If the date in fields 19 and 28 are completed but do not meet requirements, providers will be given the opportunity to submit documentation to correct the date if errors need to be corrected. If these dates of signatures are missing, the consent form will receive a final denial and cannot be resubmitted to TMHP.

Providers must use the space indicated in the Denial Letter to submit corrections to TMHP. Providers must not resubmit a corrected Sterilization Consent Form. Only the first submission of the form received by TMHP will be processed; resubmissions of the Sterilization Consent Form will not be considered.

Fields Required for Approval: Corrections are Not Permitted

The following signature and date fields must be completed for the consent form to be approved. If applicable signatures or dates of signatures are missing, the consent form will receive a final denial and cannot be resubmitted to TMHP.

  • 3. Doctor or clinic
  • 4. Specify type of operation
  • 7. Doctor or clinic
  • 8. Specify type of operation
  • 9. Client Signature
  • 10. Date of Signature
  • 18. Signature of person Obtaining Consent
  • 19. Date of Signature (left blank)
  • 27. Physician’s Signature
  • 28. Date of Signature (left blank)

Note: If the dates in fields 19 and 28 are completed but do not meet requirements, providers will be given the opportunity to submit documentation to correct the dates if errors need to be corrected.

Review and Approval

Each submitted consent form will be reviewed and approved or denied as follows:

  • Approved
  • Denied pending correction
  • Final denial

Approved

The provider can submit the claim for consideration of reimbursement.

The provider will not receive notice of an approval. All consent forms will be processed within three business days. If the provider has not received a faxed Denial Letter by the fifth business day after submission, the provider can submit the claim for consideration of reimbursement.

Denied Pending Corrections

If information is missing, invalid, or illegible on the submitted consent form, providers will receive an Denial Letter as notification of the deficiencies found with the consent form. For required fields (other than the signature and date of signature fields), providers will have up to three opportunities to make the necessary corrections to the form using the space provided on the Denial Letter.

Important – Corrections: Providers must use the space indicated in the Denial Letter to submit corrections to TMHP. Providers must not resubmit a corrected Sterilization Consent Form. Only the first submission of the form received by TMHP will be retained; resubmissions of the Sterilization Consent Form will not be considered.

Important – Fax Number: If the Provider/Clinic Fax Number (field #33) is missing from the Sterilization Consent Form or is invalid, the provider will not receive notification of a denied consent form.

If the provider does not receive notice of a denied consent form, and the claim is denied for no consent form:

  1. The provider can call the TMHP Contact Center at 800-925-9126 for information about the denied claim and the consent form.
  2. The TMHP Contact Center will fax the “Sterilization Consent Form: Request for Fax Number” form to the provider.
  3. The provider must complete the “Sterilization Consent Form: Request for Fax Number” form with the appropriate fax number, and fax the document to the TMHP Family Planning Unit at 512-514-4229.
  4. The TMHP Family Planning Unit analyst will fax the provider the Denial Letter with the information of each deficiency that requires correction.

Upon receipt of the Denial Letter, the provider can take action as necessary and complete the consent form approval process before appealing the claim for consideration of reimbursement.

As a reminder, claims must meet all filing deadlines to be considered for reimbursement.

Final Denial

The submitted consent form will receive a final denial for the following reasons:

  • The provider has exhausted 3 attempts to correct all missing, invalid, or illegible information on the consent form.
  • The Consent to Sterilization section is missing one or more of the following fields or the information provided does not meet requirements: 3 Doctor of clinic, 4 Specify type of operation, 7 Doctor or clinic, 8 Specify type of operation, 9 Client Signature, or 10 Date of Signature.
  • The information provided does not meet requirements.
  • The Sterilization Consent Form that is submitted is the wrong version. Providers must use the current version of the consent form as posted to the TMHP website at www.tmhp.com.
  • One or more signatures or dates of signature is missing or does not meet requirements. All applicable signatures and dates must be on the consent form upon submission and must be original, handwritten, and unaltered.

If the consent form has received a final denial, corrections will not be considered by TMHP, and all related claims will be denied.

Refer to: The Texas Medicaid Provider Procedures Manual, Volume 1, Section 7.3, “Appeals to HHSC Texas Medicaid Fee-for-Service,” for additional information about appeals options.

Sterilization Consent Form

Effective September 1, 2016, the Sterilization Consent Form has been updated as follows:

  • Asterisks have been added to indicate required fields.
  • All fields have been numbered for easier identification
  • The instructions have been updated to accommodate the updates to the approval process.
  • The initial submission and correction check boxes have been removed from the top of the form.
  • The Program section has been removed from the bottom of the form.
  • The information fields have been made fillable so that the information can be typed into each field before the form is printed and signed and dated.

Important: This form is fillable. The information can be typed into the form electronically. This form cannot be electronically signed or dated. After the required fields have been completed, the form must be printed and signed and dated by all necessary parties. Only handwritten wet signatures and signature dates are accepted.

Providers can continue to use the previous version (Effective Date_09012014/Revised Date_01212014) of the Sterilization Consent Form until March 31, 2017. Beginning April 1, 2017, providers must use only the new version of the form (Effective Date_09012016/Revised Date_05312016). All previous versions of the form will receive a final denial.

For more information, call the TMHP Contact Center at 800-925-9126 (select Option 2 and then Option 3).